Enrollment Form

Step 1 of 6

Student Health
Plan Details

Student
Verification

Student
Information

Insurance
Details

Additional
Documents

Enroll Form
Submission

Enrolling in the ATSU Student Health Insurance Plan

If you wish to enroll in the student health insurance plan for the 2024/2025 academic year, you must submit your enrollment via the Health Sciences Assurance Consulting (HSAC) website. The earlier you submit your enrollment, the sooner you will receive your plan materials (brochure, ID card). Students enrolling after the plan begins will have their coverage backdated to the plan's start unless they have experienced an involuntary loss of coverage.

HSA Consulting, Inc. (HSAC) is the group administrator for the student health plan. All information submitted is confidential and utilized for health insurance only. You will be receiving emails from HSAC from this point forward, so please make sure to review the information they are providing you. As the group administrator HSAC will assist students with plan questions, address changes, claims assistance, and obtaining ID cards. Their team is available by phone or email, HSA Consulting, Inc. (888-978-8355) or atsu@hsac.com with any questions regarding the waiver/enrollment process or the student health insurance plan.

ATSU Enrollment Deadlines

All enrollment deadlines are determined by the ATSU. HSAC does not make exceptions to deadlines or the ATSU student insurance policy.

Cohort	Start Date	Open Enrollment Period
Continuing Students	07/01/2024	05/15/2024-06/30/2024
Incoming Students	07/15/2024	05/15/2024-07/12/2024
Incoming MSO Students	07/08/2024	05/15/2024-07/12/2024
Incoming CCPA Students	10/07/2024	05/15/2024-09/30/2024
Ortho 2026	07/03/2024	05/15/2024-06/30/2024
2nd Year SOMA Students	07/01/2024	05/15/2024-08/31/2024
Incoming Students - 01/06/2025	01/06/2025	12/01/2024-12/31/2024

2024-2025 ATSU Student Insurance Plan Details

Deductible	$750.00 In-Network
Co-Insurance	80% In-Network
Out of Pocket Max (Individual)	$7,150.00 In-Network
Office Visit	$30 Copayment, 100% not subject to deductible In-Network
Emergency Room Visit	$150 Copayment (Waived if Admitted), 80% Co-Insurance In-Network and Out-of-Network
Prescription Drugs	$20/$40/$60

Cohort	Coverage Start	Coverage End	Premium	Fall Premium	Spring Premium
Continuing Students	07/01/2024	06/30/2025	$4,376.00	$2,188.00	$2,188.00
1st Time Incoming Students	07/15/2024	06/30/2025	$4,209.00	$2,021.00	$2,188.00
CCPA Students	10/07/2024	06/30/2025	$3,202.00	$1,014.00	$2,188.00
MSO Students	07/08/2024	06/30/2025	$4,293.00	$2,105.00	$2,188.00
Ortho 2026	07/03/2024	06/30/2025	$4,293.00	$2,105.00	$2,188.00

2024-2025 ATSU Student Vision Insurance Plan

	In-Network	Out of Network
In-Network Exam	$10 Copay	$40 Reimbursement
In-Network Lenses	$75 Copay	$40 Reimbursement
In-Network Contact Lenses	$150 Allowance + 15% off Balance	$120 Reimbursement
In-Network Frames	$150 Allowance + 20% off Balance	$120 Reimbursement

2024-2025 ATSU Student Dental Insurance Plan

Deductible	$50.00
Plan Year Maximum	$1,000.00
Co-Insurance	-
Preventative/Diagnostic	100%
Basic	80%
Major	50%

Student Verification

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

First Name*

Last Name*

Date of Birth (mm/dd/yyyy)*

Student Information

Please enter your information. Fields with * are required.

Personal Info

First Name*

Middle Initial

Last Name*

Date of Birth (mm/dd/yyyy)*

Gender*

Social Security Number*

Student ID*

Graduation Year*

Program*

Address

Home Address*

Home Address 2

Home City*

Home State*

Home Country*

Home ZIP Code*

Contact Info

Phone Number*

Personal Email*

University Email*

Insurance Details

Option 1Medical, Vision, and Dental

Requested Enrollment Date (mm/dd/yyyy)

Additional Documents

If you have any extra documents you would like us to have, please upload them here.

Document 1
Document 2

Document 1

Choose

Drag and drop a file here to upload.

Document 2

Choose

Drag and drop a file here to upload.

Enrollment confirmation

Please confirm the information you entered, then click submit.

Student Information

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

Medical Insurance Information

Medical	Yes
Dental	Yes
Vision	Yes
Requested Enrollment Date

Documents

Document 1
Document 2

Attestation

Insurance Fraud Warning: Any person who knowingly presents a false or fraudulent claim for payment of a loss of benefits or knowingly presents false information in an insurance application is guilty of a crime and may be subject to fines and confinement in prison.

Student signature. 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.

Electronic Consent

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy. Upon submitting this electronic form, you will receive an email with a link to your submission in PDF format, which you can download or print for your own retention. To view the PDF, you will need access to a personal computer with an internet browser, internet connection and PDF reader software. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

Comments

Signature*

Date*

Your enrollment form has been successfully submitted!

Your confirmation number is: #

You will receive an automatic email confirming your online submission along with your confirmation number.

Please allow 3-5 business days for your application to be processed. Once completed, you will receive an email either confirming your enrollment has been approved or that additional information is needed in order to process your request.

Enrollment Form

Enrolling in the ATSU Student Health Insurance Plan

ATSU Enrollment Deadlines

2024-2025 ATSU Student Insurance Plan Premiums

Student Verification

Student Information

Insurance Details

Additional Documents

Enrollment confirmation

Your enrollment form has been successfully submitted!