Important Forms
Our office is experiencing a high volume of requests. Please allow 10 BUSINESS DAYS for our office to process your request. You will be notified by email of our decision.
Notices:
- The policy year corresponds to the August-to-August academic year, not the calendar year. See dates here.
- Students cannot submit petitions for a policy year that has already ended.
- The deadline to submit a Petition to Waive for any 2024-25 coverage period is 11:59 p.m. EST on August 18, 2025.
- If you experience a Qualifying Event and wish to modify an existing selection or waiver, submit the Qualifying Event 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:
NOTE: Students that are NEW to the university for AUTUMN 2024 should complete the annual Select/Waive process for the 2024-2025 plan year in My Buckeye Link prior to the August 13, 2024, deadline.
- 2024-25 Petition to Waive - Domestic Students
- Use this form if: 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 are a domestic student who missed the Select/Waive deadline OR My Buckeye Link would not let you waive.
- 2024-25 Petition to Waive - International Students
- Use this form if: You are an international student who meets waiver criteria.
- Use this form if: You are an international student who meets waiver criteria.
- 2024-25 Petition to Enroll
- Use this form if: You missed the Select/Waive deadline or have special academic circumstances.
- Use this form if: You missed the Select/Waive deadline or have special academic circumstances.
- 2024-25 Qualifying Event
- 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.
Early Arrival Coverage Forms:
Eligibility for Early Arrival Coverage is defined here.
2023-24 FORMS (AU23, SP24, SU24)
Notices:
- Students cannot submit petitions for a policy year that has already ended. The deadline to submit a Petition to Waive for any 2023-24 coverage period is 11:59 p.m. EST on August 12, 2024.
- The policy year corresponds to the August-to-August academic year, not the calendar year. See dates here.
MEMBER FORMS
- 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.