Health Care Worker Bonus Employee Inquiry

Please fill-out all the following required fields in order to submit your health care worker bonus employee inquiry. Click here to see the instructions for filling out this form. If you have questions related to this inquiry, send an email to bmfahwb@omig.ny.gov, or call 518-402-6231.

* Required field

Section 1: Employee Information

First Name:*

Last Name:*

SSN/ITIN:*

Address:*

City:*

State:*

Zip Code:*

Phone Number: (e.g.(XXX) XXX-XXXX)*

Email Address:*

Additional Detail (Employee Job Duties and Other Information):*

Is someone other than the employee submitting this inquiry?

Yes No

Section 2: Preparer (only complete this section if someone other than the employee is submitting this inquiry)

First Name:*

Last Name:*

Preparer Date of Birth:(e.g.MM/DD/YYYY)*

Preparer Address:*

City:*

State:*

Zip Code:*

Preparer Phone Number: (e.g.(XXX) XXX-XXXX)*

Preparer Email Address:*

Section 3: Employer Information

Employer Name:*

Vesting Period:*

NPI (if known):

FEIN (Can be found on W2 form):*

MMIS ID/SFS Vendor ID (if known):

Employer Address:*

City:*

State:*

Zip Code:*

County:*

Employer Phone Number: (e.g.(XXX) XXX-XXXX)*

Employer Email Address (if known):

Employee Job Title:*

Employee Average Hours In Vesting Period:*

Employee Base Salary in Vesting Period:*
Note: This is not your annual salary. Please see instructions in link at top of page.

Bonus Amount Already Paid for Vesting Period:*

Current Employee (Y/N):*

Date of Employment - Start:(e.g.MM/DD/YYYY)*

Date of Employment - End:(e.g.MM/DD/YYYY)*

Click this button to add an additional Employer/Vesting Period ->