Student Health Insurance Program Waiver Form - 2019-2020

Waiver Process

Maintaining health insurance coverage is mandatory for all full-time WVSOM students and all students MUST be covered by a domestic health insurance plan. All students are required to enroll in the WVSOM - Sponsored Student Health Insurance Plan unless an acceptable Waiver is provided by the designated deadline. The acceptable coverage to waive the WVSOM - Sponsored Student Health Insurance Plan is a parent's employer group plan, a spouse's employer group plan, a student's own employer group plan, West Virginia Medicaid  (1st and 2nd year students only), VA Benefits or COBRA.  Individual Plans will be accepted for the 2019-2020 Policy year as long as they meet the waiver requirements.  Individual plans will be verified on a quarterly basis.

If you have active health insurance with benefits which meet the criteria below you may apply for waiver of enrollment in the WVSOM plan. You will need to have your current insurance ID card and information regarding your plan benefits to complete the process. A copy of the front and back of your Health Insurance ID card must be submitted with your request. Once you have submitted the required information you will receive an email verifying if your waiver meets the WVSOM requirements. Waivers will be accepted until June 15, 2019 for the fall semester. Please be aware that you will be automatically enrolled in the health insurance plan and the health insurance charge will remain on your account if a waiver request is not completed and approved. Waiver requests will not be accepted after the June 15, 2019 deadline for the 2019-2020 Policy Year Spring Semester.

By submitting your waiver request you are acknowledging that you have read the Waiver Requirements and agree to abide by the WVSOM Insurance Policy.

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

The waiver period for the 2019-2020 policy year will open May 17, 2019. You must submit a copy of the front and back of your Health Insurance ID card with your waiver submission.

Please enter your information. Fields with * are required

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

The waiver period for the 2019-2020 policy year will open May 17, 2019. You must submit a copy of the front and back of your Health Insurance ID card with your waiver submission.

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 wvsom@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.

Please Confirm the information you entered, then click submit.

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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