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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2015-2016 Policy

2015 Benefit Summary (PDF)

2015 Continuation Enrollment Form (PDF)

2015 Dependent Enrollment Form (PDF)

2015 Plan Brochure (PDF)

2015-2016 Student Insurance Enrollment Request form (online-no longer open for submission)

2015-2016 Student Insurance Waiver Decision Appeal (online-no longer open for submission)

2015-2016 Student Insurance Waiver Request form (online-no longer open for submission)

2015 Voluntary Dental Plan Benefit Summary (PDF)

2015 Voluntary Dental Plan Enrollment Form (PDF)

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2016-2017 Policy

2016 Benefit Summary (PDF) - available 7/1/2016

2016 Continuation Enrollment Form (PDF) - available 7/1/2016

2016 Dependent Enrollment Form (PDF) - available 7/1/2016

2016 Plan Brochure (PDF) - available 7/1/2016

2016-2017 Student Insurance Enrollment Request form (online) - opened on 7/5/2016

2016-2017 Student Insurance Waiver Decision Appeal (online) - opened 06/07/2016

2016-2017 Student Insurance Waiver Request form (online) - opened 06/07/2016

2016 Voluntary Dental Plan Benefit Summary (PDF) - available 7/1/2016

2016 Voluntary Dental Plan Enrollment Form (PDF) - available 7/1/2016

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