Student Insurance Forms & Documents

2018-2019 Policy

2018 Benefit Summary (PDF)
2018 Continuation Enrollment Form (PDF)
2018 Dependent Enrollment Form (PDF)
2018 Plan Brochure (PDF)
2018-2019 Student Insurance Enrollment Request Form (online, enrollment period ended)
2018-2019 Student Insurance Waiver Decision Appeal Form (online, waiver period ended)
2018-2019 Student Insurance Waiver Request Form (online, waiver period ended)
2018-2019 Voluntary Dental Plan Benefit Summary (PDF)
2018-2019 Voluntary Dental Plan Enrollment Form (PDF)

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)

Privacy
Authorization from Individual (PDF)
Personal Representative Appointment (PDF)
SHC Release of Info to UHCSR (PDF)