Date of Birth:
(Please enter the mailing address where you want
your Insurance Card and Insurance information mailed)
Is this term your first semester on the UCD-AMC Student Injury and Sickness Health Plan?
Are you enrolled in five (5) or more credit hours of a degree
University of Colorado - Anschutz Medical Campus requires that all students taking 5 or more credit hours have health insurance and will automatically bill these students for Annual enrollment on Plan A of the University of Colorado - Anschutz Medical Campus Student Health Insurance Plan. Students with comparable health insurance coverage may waive out of enrollment on the school-sponsored health insurance plan by completing and submitting this form by June 1, 2014 for new students in the Summer semester. A NEW Waiver Form must be submitted ANNUALLY every Fall, or after a break in academic studies, when you have a change in your Policy.
Notice: Any person who unknowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading
information concerning any fact material commits a fraudulent insurance act, which
is a crime, and shall be subject to a civil penalty not to exceed five thousand
dollars and the stated value of the claim for each such violation.
Comparable health insurance coverage means that your health plan meets ALL of the
following waiver criteria:
- The annual deductible must be no more than $1,500 per Policy Year (HSA's are not
- There is no less than a $1,000,000 per Policy Year; and
- Co-insurance is no more than 30%, if applicable; and
- Coverage must include comprehensive services (inpatient and outpatient benefits
($10K or more per Sickness or Accident for outpatient services) in the State of
Colorado and benefits cannot be for Emergency Services only (Hospital Only (CICP),
Accident Only, Short Term Medical & Student Select plans do not qualify); and coverage
must not be an alternative to health insurance, such as a medical share plan; and
- Coverage must include outpatient mental health benefits of at least 10 visits per
year, at a payment of 50% or higher co-insurance level; and
- Coverage must include inpatient mental health benefits at a payment of 50% up to
a minimum of $10,000 per Policy Year; and
- Coverage must include retail pharmacy benefits, both generic and brand drugs with
an Annual Rx Deductible that does not exceed $1,000 per year.
By my signature I agree the above statements are true and agree to immediately notify
the Student Health/Insurance Office of any changes in my contact information or
my health insurance policy information. Any approved waiver is good for the Plan
Year 2013-2014 only and I understand that I must submit a new Waiver Form annually,
after a break in academic studies, or when I have a change in my Policy. I understand
that falsification of information used to waive insurance is a violation of the
University of Colorado Anschutz Medical Campus Student Honor Code. The school
does an audit on every waiver form received. If it is found that the information
provided to waive the school’s plan is no longer valid, or that your insurance plan
does not have comparable coverage, you will be automatically enrolled on Plan A
and charged the full premium.
I waive enrollment on the Plan Year 2013-14 University of Colorado Anschutz Medical Campus Student and Injury Sickness Plan as my insurance policy meets the above criteria. Your insurance plan must have been effective June 1, 2014, for New Students starting school in the Summer 2014 semester.
PLEASE FILL OUT
ALL APPROPRIATE BOXES
Last Name of Primary Policy Holder: *
Date of Birth of Primary Policy Holder:*
Student's Relationship to Primary Policyholder*:(check one)