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Student Health Insurance Plan
Downloadable Forms

Some of the files on this site are provided in portable doument format (pdf). A program that can read and/or print pdf files, like Adobe Acrobat Reader, may be required.

2009-2010 Academic Year Forms

Enrollment and Waivers

  • Online Waiver Application- Students who have existing insurance coverage may apply for a waiver application online. The online interface will give an instant approval/denial at the time of submission and credit your account if appropriate.
  • Paper Waiver Application - *only for students who are unable to use the online waiver application or require multiple forms of insurance to qualify.
  • Appeal of Waiver Denial - Students may appeal a waiver denial within two weeks of receiving notice of denial.
  • Request to Cancel Waiver (pdf)- Students may cancel an approved wavier application and enroll in SHIP.
  • SHIP Enrollment Form- Students whose registration status has changed (e.g., PELP, Filing Fee, 1st quarter after graduation) may apply for a one-quarter extension of their SHIP coverage.

2008-2009 Academic Year Forms

Enrollment and Waivers

  • Online Waiver Application - not available for the 2008-2009 academic year
  • Paper Waiver Application - not available for the 2008-2009 academic year
  • Appeal of Waiver Denial - not available for the 2008-2009 academic year
  • Request to Cancel Waiver (pdf)- Students may cancel an approved wavier application and enroll in SHIP.
  • SHIP Enrollment Form - Students whose registration status has changed (e.g., PELP, Filing Fee, 1st quarter after graduation) may apply for a one-quarter extension of their SHIP coverage.

SHIP Claim Forms

  • SHIP Medical Claim Form (pdf)- When SHIP members receive services from a health care provider, the provider will normally bill Blue Cross directly for those services. Sometimes, however, a physician, an ambulance company, or another provider may send the bill for services directly to the student. You may supply this claim form to your health care provider, or use it yourself in the event that the provider does NOT file the claim for you.
  • SHIP Prescription (Rx) Claim Form (pdf)- When SHIP members buy a prescription drug at a pharmacy other than the Cowell Student Health Center pharmacy, you are entitled to receive a 50% reimbursement of your cost from Blue Cross. Use this form, along with your itemized pharmacy bill to receive reimbursement.

 

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