Student Health Insurance Program Waiver Form - 2021-2022

To begin the waiver process please enter your demographic information below and click the "next" button at the bottom to continue.

Please enter your information. Fields with * are required

HELPFUL HINTS:
* For incoming students if you do not know your AMC email address yet you may enter your personal email address instead.

Please enter your medical insurance information. Fields with * are required

HELPFUL HINTS:
* Insurance Name: If your insurance is not listed, scroll to the bottom and select “Not Listed – Type My Own”
* Member/Subscriber Number: This is your insurance ID number. DO NOT PUT YOUR NAME IN THIS BOX.
* Insurance Plan Type: If you don’t know it, select “Other”.
* Insurance Address: Is the claims mailing address on the back of your insurance card. If you cannot locate it, type your mailing address instead.
* Provider Services Phone Number: Either the provider or member services number listed on the back of your medical ID card is acceptable.
* Requested Termination Date: This field is not required and only applies if you are currently enrolled in the student health plan and are submitting a waiver to have your enrollment terminated.

Please enter your dental insurance information. Fields with * are required

If you have any extra documents you would like us to have, please upload them here. Only .doc, .docx and .pdf files are accepted. Up to two documents may be uploaded. Each document may be no larger than 5 Megabytes. If a document is larger than 5 Megabytes, please forward via email to amc@hsac.com.

***** Attach copies of the front and back of your insurance ID card or forward copies via email to Trish@hsac.com. Copies may be pictures taken with a camera or smart phone as long as they are legible. *****

***** If you have a separate prescription ID card you will also need to attach or email copies of the front and back of that ID card as well. ******

Please Confirm the information you entered, then click submit.

Student Information

Last Name
Middle Initial
1
First Name
Gender
Social Security Number
Student ID
Home Address
Home Address 2
Home City
Home State
Home Country
Home Zip
Phone Number
Personal Email
University Email
Date of Birth

Medical Insurance Information

Insurance Name
Group Number
Member/Subscriber Number
Insurance Plan Type
Insurance Address
Insurance Address 2
Insurance City
Insurance State
Insurance Zip
Provider Services Phone Number
Source of Coverage
Subscriber First Name
Subscriber Last Name
Subscriber Relation
Subscriber Date of Birth
Requested Termination Date

Documents

Document 1
Document 2

I hereby submit proof of personal health insurance and decline the sponsored Student Health Insurance Plan. I acknowledge that I am legally responsible for any and all medical expenses incurred by myself/dependant while enrolled.

Student Signature (or Parent's Signature if student is under Age 18)**

** By typing your name in the Signature field, you hereby certify that the information entered into this form is true and correct to the best of your knowledge.

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