Student Insurance Forms & Documents


General

Claim Information Form (PDF)

Global Emergency Services Program Guide (PDF)

Notice of Change of Insurance (PDF)

Payment of Out-of-Network Benefits (PDF)

Pharmacy Claim Form (PDF)

UnitedHealth Allies Discount Program Member Handbook (PDF)

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Privacy

Authorization from Individual (PDF)

Personal Representative Appointment (PDF)

SHC Release of Info to UHCSR (PDF)

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2016-2017 Policy

2016 Benefit Summary Brochure (PDF)

2016 Summary of Benefits & Coverage (PDF)

2016 Continuation Enrollment Form (PDF)

2016 Dependent Enrollment Form (PDF)

2016 Plan Brochure (PDF)

2016-2017 Student Insurance Enrollment Request form (online) - now closed; Summer 2017 College Enrollment Request Form

2016-2017 Student Insurance Waiver Decision Appeal (online) - now closed

2016-2017 Student Insurance Waiver Request form (online) - now closed

2016 Voluntary Dental Plan Benefit Summary (PDF)

2016 Voluntary Dental Plan Enrollment Form (PDF)

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2017-2018 Policy

2017 Benefit Summary (PDF) - available on or around 6/15

2017 Continuation Enrollment Form (PDF) - available on or around 7/1

2017 Dependent Enrollment Form (PDF) - available on or around 7/1

2017 Plan Brochure (PDF) - available on or around 7/1

2017-2018 Student Insurance Enrollment Request form (online) - available on or around 7/1

2017-2018 Student insurance Waiver Decision Appeal (online) - available on or around 6/1

2017-2018 Student Insurance Waiver Request form (online) - available on or around 6/1

2017-2018 Voluntary Dental Plan Benefit Summary (PDF) - available on or around 7/1

2017-2018 Voluntary Dental Plan Enrollment Form (PDF) - available on or around 7/1

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