Please enter your information. Fields with * are required
* 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
* 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.
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 email@example.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.
- Last Name
- Middle Initial
- First Name
- 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
- 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.
Your waiver is being uploaded. If you attached any files this may take a few moments.