St. Mary's University

Student Health Insurance Summer 2014, Domestic Online Waiver

Deadline for Submission: May 30, 2014

The university requires that each dormitory student, athlete and international student participate in the Student Health Insurance Plan unless proof of comparable coverage is submitted. If you are a domestic U.S. born student, please complete the waiver below. By submitting this information you are providing proof of personal health insurance to apply to the 2013-2014 academic year.

If you are an international student (including international athletes), please do not complete the waiver below. You must go back to the previous page and click on International students on the right side of the screen and follow the instructions provided.

SECTION A
* First Name:
Middle Name:
* Last Name:
* St. Mary's Email Address:
* Phone:
* Gender:
* Date of Birth:
* Student ID:
SSN:
Alt. Phone:
SECTION B
Emergency Contact Information
* First Name:
* Last Name:
* Phone:
* Relationship:
 
Primary Care Physician (Family Physician)
Name:
Phone:
SECTION C
Health Insurance Information
Insurance Company Address
* Company:
Address:
 
City, State:
Zip Code:
* Phone:
Policy Holder Information
* Name
SSN:
* Birthdate:
* Insurance Type: (HMO,PPO,POS,...)
* Group # / Plan:
* Policy # (ID):
 
SECTION D

Are you a Student Athlete?
If No, Please disregard SECTION D and continue with SECTION E
If Yes, which sport?
Do you have military insurance (Tri-Care)? If yes, You are not eligible to waive.  
Does your health insurance cover athletic related injuries?
Does your health insurance provide coverage for Dr. Jesse De Lee, The Nix Orthopedic Center of South Texas (Team Physician)?
Does this insurance require you to pay a deductible?
If you have a deductible, how much must you pay? $
Does this insurance require a referral before treatment?
Does this insurance cover orthopedic braces?
Do you have any other accident insurance in addition to the policy information provided above?
If Yes, List Company?
All students will be able to use the Student Health Center in case of sickness. If an athlete does not carry the student injury and sickness insurance plan, their account will be billed for any service rendered.
Are you covered by a separate dental insurance plan?
Name of carrier:
Policy Number:
SECTION E

I hereby submit proof of personal health insurance and decline the St. Mary's University sponsored Student Health Insurance Plan. I acknowledge that I am legally responsible for any and all medical expenses incurred by myself/dependant while enrolled.

I know it is a crime to fill out this form with facts I know are false or leave out facts I know are important. I certify that the information furnished by me is true and correct. I further agree to notify St. Mary's University or St. Mary's University Athletics Department immediately in writing if my insurance policy expires or changes during my attendance.

Please be advised that it is your responsibility to enroll in the Student Health Insurance Plan or find comparable health coverage if your insurance status changes. You can contact Academic HealthPlans at 855-357-0238 should you need any information on the St. Mary's University Student Health Insurance Plan

Student's Signature (or Parent's Signature if student is under Age 18)** Date
** By typing your name in the Signature field, you hereby certify that the information entered into this form is true and correct.


You will receive Email confirmation of this submission.