CSM Student Health Insurance Plan (SHIP) Spring 2014 Waiver Request Form

Students who are subject to CSM’s mandatory health insurance requirement and fail to submit this form by January 23, 2014 will be automatically enrolled in the SHIP.

INSTRUCTIONS:

·  This form must be completed by all students who are (1) registered for classes for the Spring 2014 semester; and (2) subject to CSM’s requirement for student health insurance coverage.

·  Refer to the SHIP Plan Brochure for details about the plan or go to http://ship.mines.edu

·  If you have questions regarding the insurance requirement or the SHIP, call the Student Health Benefits Coordinator at 303.273.3388

or email

·  If you are waiving the SHIP, all coverage statements must be confirmed (See Section 2 below).

Section 1 Student Information (Required)

(Please Print)

CWID: Last Name: First Name: Middle Initial:

Birth Date: Address: City: State & Zip:

Phone # with Area Code: Mines Email Address:

Circle One: Domestic Undergraduate Domestic Graduate International Undergraduate International Graduate

Section 2 Request to Waive Enrollment in the SHIP [All requirements must be met.]

I request to waive enrollment in the SHIP based on the existence of health insurance that meets or exceeds each of the following coverage requirements (you must initial each statement that applies to your coverage in order to waive the SHIP)

___The plan has a lifetime maximum benefit is at least $2,000,000 with no yearly or per condition maximum benefit that would reduce coverage.

___ The plan includes participating health care providers (i.e. hospitals, physicians, pharmacies and mental health care providers) in the Denver metro area for both emergency AND non-emergency health care services.

___The plan includes prescription drug benefits.

___ The plan provides at least 20 outpatient visits for mental health care services and provides at least 30 days of inpatient mental health care services (including emergency psychiatric admissions).

___ Coverage will be in effect as of January 8, 2014 without any waiting period or pre-existing condition exclusion.

___ The plan will remain in effect from January 8, 2014 to August 17, 2014, except for termination due to attainment of a maximum age or other condition resulting in loss of plan eligibility.

___ The plan does not have a deductible greater than $5000

___If you travel abroad during the 2013-2014 academic year as part of a CSM program, will your plan provide medical coverage including medical evacuation and repatriation or if it does not, you will purchase other individual insurance that provides comparable international travel coverage?

Name of Insurance Company:

Policy/Group Number:

Phone Number to verify coverage:

Name of employer providing coverage (if applicable):

Claims Address: ______

I hereby attest that the statements on this page are valid and accurate. I understand that any willful falsification of the information on this page is a violation of the CSM student code of conduct. I understand that all information on this page is subject to audit by CSM, and I authorize CSM to contact my health insurance provider regarding my coverage . I further understand that I will be enrolled in the SHBP as an Unqualified Late Enrollee if I am discovered to be without health insurance during the 2013-2014 academic year.

Student Signature: Date:

(Must be signed by Parent or Guardian if under 18)

Revised January 2, 2013