Creating the Extraordinary Student Experience

2016-17 Important Forms

 

NOTICES:

  • You cannot modify or drop coverage term-to-term if you are currently enrolled in the Comprehensive Plan. With the exception of a Qualifying Event, your initial Comprehensive Plan selection stays in effect until the end of the policy year (August 2017) assuming you maintain academic eligibility. 
  • If you experience a Qualifying Event, you can request to modify, add, or drop Comprehensive Plan coverage by submitting the Coverage Status Change form below. Do not submit a Petition to Waive or Petition to Enroll.
  • The student health insurance policy year corresponds to the academic year, and runs August to August. Specific dates can be found here.
  • The forms below apply to Autumn 2016, Spring/Summer 2017, or Summer 2017 terms. For 2015-16 forms, visit here.

FORMS:

2016-17 Petition to Waive

**If you submitted a Petition to Waive on December 29 between the hours of 8am and 4:30pm, unexpected system errors caused your data to be lost. Please resubmit or contact us directly.** 

For International students who can demonstrate Minimum Health Insurance Criteria, OR

For Domestic students who failed to submit a waiver by the Select/Waive deadline or who were unable to use their My Buckeye Link to waive before the deadline. 

2016-17 Petition to Enroll                                                                                                                            

For students in academic circumstances that prevent them from completing Select/Waive through My Buckeye Link, or for students who failed or were unable to select prior to the Select/Waive deadline.

2016-17 Coverage Status Change

For students who wish to ask to add or terminate Comprehensive Plan coverage due to experiencing a Qualifying Event and who meet eligibility requirements. **Members called up to Active Duty in the armed forces in the middle of a term and wishing to terminate coverage should contact our office for assistance**

2016-17 HealthSmart Insurance Response Form

For Comprehensive Plan members who have been contacted about a claim by HealthSmart Benefit Solutions and who need to submit a response back to HealthSmart. This form is identical to the one members would receive in the mail from HealthSmart attached to an Explanation of Benefits (EOB).

2016-17 HealthSmart Accident Details Form

For Comprehensive Plan members who have been contacted about an accident-related claim by HealthSmart Benefit Solutions and who need to submit a response back to HealthSmart. This form is identical to the one members would receive in the mail from HealthSmart. 

2016-17 Interim Insurance - International 

For early arriving international students who meet eligibility requirements and wish to request up to four weeks of Comprehensive Plan coverage prior to the start of the term for which they would otherwise select the Comprehensive Plan. Up to 4 weeks of additional coverage are allowed if approved.

2016-17 Interim Insurance - Domestic

For early arriving domestic students who meet eligibility requirements and wish to request up to four weeks of Comprehensive Plan coverage prior to the start of the term for which they would otherwise select the Comprehensive Plan. Up to 4 weeks of additional coverage are allowed if approved.

Affidavit of Domestic Partnership       

For students and/or current Comprehensive Plan members to document same-sex or opposite-sex domestic partner relationship for purposes of covering an eligible partner as a dependent on their policy. Required for enrolling a dependent during a Select/Waive period and when submitting a Coverage Status Change (newly meeting the Domestic Partnership requirements is a Qualifying Event). Form must be notarized. 

Termination of Domestic Partnership

For current Comprehensive Plan members to document termination of a covered domestic partner relationship when submitting a Coverage Status Change (new termination of a Domestic Partnership is a Qualifying Event). Note: If the partnership terminates during the middle of a coverage period, the coverage for the domestic partner and associated fee will remain effective through the end of the period. 

Medical Claim Prescription Drug Claim 

For 2016-17 Comprehensive Plan members who need to file a claim to HealthSmart.