Documentation Required for Health and Dental Plan Enrollment

Enrollment in Endowed Health and Dental Plans 

In addition to completing the applicable endowed health and/or dental enrollment in Workday (or enrollment form(s) if applicable), you must provide documents to support your dependent’s eligibility for coverage as outlined below.

Send the endowed health and/or dental enrollment form(s) (if applicable) and supporting documentation to Benefit Services, 395 Pine Tree Road, East Hill Office Building, Suite 130, Ithaca, New York 14850.

  • Important: the IRS requires employers to provide the Social Security Number (SSN) for employees and dependents who enroll in their health care plans as part of the Affordable Care Act (ACA) SSN reporting regulations. Be sure to enter the SSN for you and your family members in Workday if you decide to enroll in an endowed health plan.

Documentation Requirements for Endowed Employees

To enroll a spouse, you must provide:

  • Copy of marriage certificate

To enroll a domestic partner, you must provide:

To enroll natural, adopted or stepchildren in the endowed health plan, you must provide:

  • Copy of birth certificate or visa and/or passport
  • Court order confirming custody (adopted child)

NOTE: When adding a natural or stepchild to your endowed health or dental plan, documentation is required to establish paternity when a father is not married to a child’s mother and the father’s name is not listed on the child’s birth certificate: in this case, the father is required to produce one of the following documents in order to add the child to endowed health and/or dental plan coverage:

  • The child’s birth certificate noting his status as the father;
  • A court order noting that his status as the father has been adjudicated by a court;
  • A voluntary acknowledgment of Paternity that has been executed and filed with the County Registrar of the county in which the child was born (all states have a paternity acknowledgment process; if the child was born in another state, the enrollee may produce a filed Voluntary Acknowledgment of the Paternity from the other state.)
  • If an employee cannot or does not produce adequate documentation to establish that he is the child’s father, he can still add the child as a dependent as an “other child.”

To enroll “Other” children, you must provide:


Enrollment in the NYSHIP Heath (Empire Plan or HMO) and/or Dental Plans

In addition to completing the PS-404 enrollment form, you must provide written documents to support your and/or your dependent’s eligibility for coverage.

Send the PS-404 enrollment and supporting documentation to Benefit Services, 395 Pine Tree Road, East Hill Office Building, Suite 130, Ithaca, New York 14850.

Documentation Requirements for Contract College Employees

To enroll an employee, NYS requires:

  • Copy of birth certificate (Copy of visa and/or passport is accepted for non-US citizens or US citizens born abroad if birth certificate is not available)
  • Copy of Social Security card or ITIN (Individual Taxpayer Identification Number)

To enroll a spouse, NYS requires:

  • Copy of birth certificate (Copy of visa and/or passport is accepted for non-US citizens or US citizens born abroad if birth certificate is not available)
  • Copy of Social Security card or ITIN (Individual Taxpayer Identification Number). (If your spouse is not a US citizen, and is not eligible to work in the United States, and as such does not have a Social Security Number or ITIN, please note this on the PS-404)
  • Copy of marriage certificate, and
  • If marriage took place over one year ago, you will need to provide proof of current joint ownership/joint financial obligation such as prior year joint tax return. If tax return is not provided, a copy of current bank statement, mortgage statement or homeowner’s policy may be provided. This must be dated within the current year.

To enroll natural, adopted or stepchildren, NYS requires:

  • Copy of birth certificate required.
    • If adding a newborn, the footprint page from the hospital may be used temporarily to enroll the child. If footprints are provided for a newborn, copies of the birth certificate and Social Security card must be submitted as soon as available.
  • Copy of Social Security card or ITIN (Individual Taxpayer Identification Number). (If your child is not a US citizen, and is not eligible to work in the United States, and as such does not have a Social Security Number or ITIN, please note this on the PS-404).
  • If applicable, proof of disability (a completed PS-451 – Statement of Disability). Contact Benefit Services at (607) 255-3936 or via email at benefits@cornell.edu to request this form.

NOTE: When adding a natural or stepchild to your plan, the New York State Department of Civil Service requires documentation to establish paternity when a father is not married to a child’s mother and the father’s name is not listed on the child’s birth certificate: in this case, the father is required to produce one of the following documents in order to add the child to NYSHIP coverage:

  • The child’s birth certificate noting his status as the father;
  • A court order noting that his status as the father has been adjudicated by a court;
  • A voluntary acknowledgment of Paternity that has been executed and filed with the County Registrar of the county in which the child was born (all states have a paternity acknowledgment process; if the child was born in another state, the enrollee may produce a filed Voluntary Acknowledgment of the Paternity from the other state.)
  • If an employee cannot or does not produce adequate documentation to establish that he is the child’s father, he can still add the child as a NYSHIP dependent as an “other child.”

To enroll “Other” children, NYS requires:

  • Copy of birth certificate required.
    • If adding a newborn, the footprint page from the hospital may be used temporarily to enroll the child. If footprints are provided for a newborn, copies of the birth certificate and Social Security card must be submitted as soon as available.
  • Copy of Social Security card or ITIN (Individual Taxpayer Identification Number). (If your child is not a US citizen, and is not eligible to work in the United States, and as such does not have a Social Security Number or ITIN, please note this on the PS-404).
  • If applicable, proof of disability (a completed PS-451 – Statement of Disability). Contact Benefit Services at (607) 255-3936 or via email at benefits@cornell.edu to request this form.
  • Required residence and support (a completed PS-457 Statement of Dependence). Contact Benefit Services at (607) 255-3936 or via email at benefits@cornell.edu to request this form.