Student Health Insurance Program Waiver Form - 2019-2020

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

The deadline for Medical Students and continuing PA students to submit your annual waiver is July 31st. You MUST include a copy of your Health Insurance ID card with your waiver submission. The deadline for PA 1 Students to submit your annual waiver is August 31st. You MUST include a copy of your Health Insurance ID card with your waiver submission.

Please enter your information. Fields with * are required

HELPFUL TIPS:
* Student ID is not a required field.
* If you don't know your University Email address, you may enter your personal email address instead.

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

HELPFUL TIPS:
* Insurance Name: If your insurance is not listed, scroll to the bottom and select “Not Listed – Type My Own”
* Group Number: Is not a required field.
* Member/Subscriber Number: 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: Can be either the provider or member services number listed on the back of your insurance ID card. In the event we cannot verify your coverage via our electronic system, we will need to call your insurance company to confirm eligibility.
* Requested Termination Date: IGNORE! This field is not required and does not apply to you.

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 rvu@hsac.com.

HELPFUL TIPS:
*You MUST include a copy of your Health Insurance ID card with your waiver submission.

Please Confirm the information you entered, then click submit.

HELPFUL TIPS:
* PLEASE NOTE: Once you submit your waiver request, you will receive a submission receipt advising that a confirmation email will be sent within 3-5 business days. Please allow a minimum of three full business days for verification. Also, once confirmed, it will take an additional 3-5 business days to remove the health insurance charges posted to your 2017-18 student account.

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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