2013-2014
UNIVERSITY OF COLORADO - ANSCHUTZ MEDICAL CAMPUS
STUDENT INSURANCE WAIVER FORM


THE WAIVER FOR SUMMER 2014 IS ONLY FOR NEW STUDENTS. No other students can submit a waiver at this time. If you have any other questions please call the Student Insurance Office at 303-724-7674 or via e-mail at amcstudentinsurance@ucdenver.edu.

The University of Colorado Anschutz Medical Campus Student Injury and Sickness Insurance Plan is an Annual Plan with coverage effective through August 31, 2014 and the Plan renews on September 1st of every year without the option to terminate off the plan mid-year. Enrollment for the insurance is limited to the Fall semester for Annual enrollment, except for new Students in the Spring or Summer semesters; or for students who qualify for Late Enrollment. Refunds will be made upon the entry into the armed forces of any country. Students must actively attend classes the first 31 days of the semester for which the student purchased insurance coverage. If the student withdraws from school or drops below the required credit hours within the first 31 days, a refund will be refunded if the withdrawal occurs during the first 31 days. Students who withdraw will not be entitled to any benefits during the days described and no claims received will be honored. No refunds will be issued except for entry into the armed forces or withdrawal from school within the first 31 days of the semester in which the student enrolled.


Student ID#:
(This is not the same as your SSN)
Last Name:
First Name:
Middle Initial:
Gender: (check one)
Date of Birth:
Mailing Address:
(Please enter the mailing address where you want your Insurance Card and Insurance information mailed)
Apt. or PO Box or Rural Route:
City:
Country:
State:
Zip Code:
Telephone #:
E-Mail Address:
(Please use your University of Colorado-Anschutz Medical Campus e-mail address)

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 seeking program?


Please check the box next to the program you are attending?




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 allowable); and
  • 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
Name of Insurance Company: *
If Other, please specify:
Insurance Identification/Member Number: *
Insurance Policy Group Number: *
Insurance Company Phone Number: *
Are you the Primary Policy Holder?(check one)


Questions? Please call ECI Toll Free 866.780.3824