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

You must submit a copy of the front and back of your Health Insurance ID card with your waiver submission.

• First Name *
• Last Name *
• Date Of Birth (mm/dd/yyyy) *

Please enter your information. Fields with * are required

• Last Name *
• Middle Initial
• First Name *
• Gender * - Select - Male Female X
• Social Security Number *
• Student ID
• Home Address *
• Home Address 2
• Home City *
• Home State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Home Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of theCook IslandsCosta RicaCote D'ivoireCroatia (Local Name: Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard And McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis And Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe
• Home Zip *
• Phone Number *
• Personal Email
• University Email *
• Class Year/Program 1st Year Medical Student 2nd Year Medical Student 3rd Year Medical Student 4th Year Medical Student
• Date of Birth (mm/dd/yyyy) *

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

• Insurance Name * - Select - Aetna American Postal Workers Union (APWU) AmeriChoice AvMed Health Plans Blue Cross Blue Shield Capital Districts Physicians Health Plan (CDPHP) CareSource Health Cigna CoreSource Coventry Healthcare Cox Health Plan Dean Health Plan FamilyCare Government Employees Hospital Association (GEHA) Harvard Pilgrim Health Care Health Alliance Medical Plans (HAP) Health First Health Health Net Health New England Health Partners Health Plan of Upper Ohio Valley HealthScope HealthSpring Humana Medica Meritain Health Molina HealthCare MVP National Association of Letter Carriers (NALC) Neighborhood Health Partnership Neighborhood Health Plan Oxford Health Plans Preferred One Presbyterian Health Plan Priority Health Providence Health Plan Public Employees Health Plan (PEHP) Qualcare Qualchoice The Health Plan TRICARE Tufts Associated Health Plan UMR Unicare United Healthcare UPMC Health Plan (Tristate) VA Healthcare WEB-TPA WellCare Health Plans West Virginia Medicaid Not Listed - Type My Own
• Group Number
• Member/Subscriber Number *
• Insurance Plan Type * - Select - PPO POS HMO Other
• Provider Services Phone Number *
• Source of Coverage * - Select - Parent Employer Group Spouse Employer Group Medicaid Own Employer Group Veterans Benefits Individual Plan Other
  I am covered until age - Select - 23 24 25 26 27 28 29 30 Coverage ends (mm/dd/yyyy)
  My annual re-certification month is - Select - January February March April May June July August September October November December
• Subscriber First Name *
• Subscriber Last Name *
• Subscriber Relation * - Select - Parent Spouse Self
• Subscriber Date of Birth
  (mm/dd/yyyy) *
• Requested Termination Date
  (mm/dd/yyyy)

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

• Currently Enrolled in the WVSOM Dental Plan

• Same Information As Medical
• Insurance Name * - Select - Aetna American Postal Workers Union (APWU) AmeriChoice AvMed Health Plans Blue Cross Blue Shield Capital Districts Physicians Health Plan (CDPHP) CareSource Health Cigna CoreSource Coventry Healthcare Cox Health Plan Dean Health Plan FamilyCare Government Employees Hospital Association (GEHA) Harvard Pilgrim Health Care Health Alliance Medical Plans (HAP) Health First Health Health Net Health New England Health Partners Health Plan of Upper Ohio Valley HealthScope HealthSpring Humana Medica Meritain Health Molina HealthCare MVP National Association of Letter Carriers (NALC) Neighborhood Health Partnership Neighborhood Health Plan Oxford Health Plans Preferred One Presbyterian Health Plan Priority Health Providence Health Plan Public Employees Health Plan (PEHP) Qualcare Qualchoice The Health Plan TRICARE Tufts Associated Health Plan UMR Unicare United Healthcare UPMC Health Plan (Tristate) VA Healthcare WEB-TPA WellCare Health Plans West Virginia Medicaid Not Listed - Type My Own
• Group Number
• Member/Subscriber Number *
• Insurance Plan Type * - Select - PPO POS HMO Other
• Provider Services Phone Number *
• Source of Coverage * - Select - Parent Employer Group Spouse Employer Group Medicaid Other
  I am covered until age - Select - 23 24 25 26 27 28 29 30 Coverage ends (mm/dd/yyyy)
  My annual re-certification month is - Select - January February March April May June July August September October November December
• Subscriber First Name *
• Subscriber Last Name *
• Subscriber Relation * - Select - Parent Spouse Self
• Subscriber Date of Birth (mm/dd/yyyy) *

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 dee@hsac.com.

***** Please attach copies of the front and back of your insurance ID card as it helps to expedite the verification process. ***** The additional documents must not be larger than 5 MB limit. If your submission will not go through and you receive the message "Woops something broke" the documents you submitted are too large. Please submit your waiver without the attachments and forward the attachments via email to wvsom@hsac.com.

• Document 1
• Document 2

• Comments

• Signature *
• Date *

Your waiver is being uploaded. If you attached any files this may take a few moments.