Student Health Insurance Program Waiver Form

Waiver Process

Maintaining health insurance coverage is mandatory for all full-time RVU students, and all students MUST be covered by a domestic health insurance plan. All students are required to enroll in the RVU - Sponsored Student Health Insurance Plan unless an acceptable Waiver is provided in a timely manner. All students are eligible to submit a waiver request at the beginning of each semester.  The fall submission deadline is July 31st and the spring submission deadline is December 31st. 

The acceptable coverage to waive the RVU-Sponsored Student Health Insurance Plan is:

  • Parent's Employer Group plan
  • Spouse's Employer Group plan
  • Student's Own Employer Group plan
  • COBRA
  • Military/Veterans Benefits
  • Medicaid (for the state in which you are attending classes or participating in clinical rotations)
  • Medicare

Individual health plans are acceptable by exception and will only be considered with a minimum of the following benefits:

  • Maximum Out of Pocket in-network of $8,550 out-of-network of $8,550
  • Deductible Maximum of $1,250 per Individual
  • Unlimited Lifetime Benefits
  • Unlimited Office Visits
  • Wellness Benefit
  • Comprehensive Prescription Plan (cannot be restricted to generic only)
  • Inpatient and outpatient Mental Health Benefits

If you have active domestic health insurance with benefits that meet the criteria above, you may apply for a waiver of enrollment in the RVU student health plan. You will need to have your current insurance ID card and information regarding your plan benefits to complete the process. Once you have submitted the required information, you will receive an email verifying if your waiver meets the RVU requirements. Waivers will be accepted through July 31, 2022, for Medical, Masters, and continuing PA Students and August 31, 2022, for PA 1 Students. Please be aware that waivers will not be accepted after the deadline, and any student who has not submitted a waiver request by the waiver deadline will be enrolled in and charged for the RVU student health plan. You MUST include a copy of your Health Insurance ID card with your waiver submission.

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.

By submitting your waiver request, you acknowledge that you have read the Waiver Requirements and RVU Insurance Policy, agree to abide by all policy terms and understand that HSAC will verify your insurance coverage.

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

If you receive an error message when entering your information please contact HSAC at 888-978-8355. 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.

  • Comments

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