2022-23 Forms (AU22, SP23, SU23)
Notices: Forms for the 2022-23 plan year are not yet available. Please check back after July 15th.
IF YOU are looking to select or waive for Autumn 22, you need to do this in My Buckeye Link prior to the August 16, 2022, deadline. Please do not submit a form; it cannot be processed.
2021-22 Forms (AU21, SP22, SU22)
The below forms are not to be used to select/waive AU 22. See above for select/waive instructions for AU 22
- Students cannot submit petitions for a policy year that has already ended. The deadline to submit a Petition to Waive for any 2021-22 coverage period is 11:59 p.m. EST on August 15, 2022.
- The policy year corresponds to the August-to-August academic year, not the calendar year. See dates here.
- If you experience a Qualifying Event and wish to modify an existing selection or waiver, submit the Coverage Status Change form within 31 days. Do not submit a Petition to Waive or Petition to Enroll.
- Except for Qualifying Events, the SHI Benefits Plan selection stays in effect until the end of the policy year -- assuming academic eligibility is maintained -- and students cannot modify or drop that selection term by term. For example, if a student selects the SHI Benefits Plan for autumn, they cannot waive it for spring/summer.
Enrollment Change Forms:
- Use this form if : You are an International student who meets waiver criteria OR You are a domestic student who missed the Select/Waive deadline OR My Buckeye Link would not let you waive.
- Use this form if: You missed the Select/Waive deadline or have special academic circumstances.
- Use this form if: You wish to modify your existing selection or waiver due to a Qualifying Event. Note: If you are a member of the armed forces who are required to interrupt your academic year for service, please contact us for assistance.
Domestic Partnership Forms:
Early Arrival Coverage Forms:
Eligibility for Early Arrival Coverage is defined here.
- Medical Claim / Prescription Drug Claim
- Delta Dental Claim Form
- HealthSmart Insurance Response Form (For domestic students only: Completing this form helps HealthSmart ensure claims process correctly.)
- HealthSmart Accident Details Response Form
Claims for services outside the United States:
The SHI Benefits Plan will pay for covered medical services provided outside of the United States at the Tier 2 level. You will need to pay in full and then request reimbursement within 90 days of the day of service using the medical claim for above. Claim forms and receipts must be submitted in English and U.S. dollars.
The SHI Benefits Plan will pay for covered dental services provided outside of the United States. You will need to pay in full and then request reimbursement within 90 days of the day of service using the dental claim form above. Claim forms must be submitted in English and U.S. dollars.