Student Insurance Forms & Documents
2023-2024 Policy
2023 Continuation Enrollment Form (through UHCSR MyAccount)
2023 Dependent Enrollment Form (through UHCSR MyAccount)
2023 Plan Brochure/Certificate (PDF)
2023 Schedule of Benefits (PDF)
2023 Summary Brochure (PDF)
2023 Student Insurance Opt-In/Enrollment Form (online)
2023 Student Insurance Waiver Request Form (online)
2022-2023 Policy
2022 Continuation Enrollment Form (through UHCSR MyAccount)2022 Dependent Enrollment Form (through UHCSR MyAccount)
2022 Plan Brochure/Certificate (PDF)
2022 Schedule of Benefits (PDF)
2022 Summary Brochure (PDF)
2022 Student Insurance Opt-In/Enrollment Form (online)
2022 Student Insurance Waiver Request Form (online)
General
Claim Information Form (PDF)
Global Travel Plus Assistance Service Brochure (PDF)
Notice of Change of Insurance (online)
Payment of Out-of-Network Benefits (PDF)
Pharmacy Claim Form (PDF)
Pharmacy Prescription Drug List (PDF)
UnitedHealth Allies Discount Program Member Handbook (PDF)
Privacy
Authorization from Individual (PDF)Personal Representative Appointment (PDF)
SHC Release of Info to UHCSR (PDF)