Student Affairs » Student Health » Student Health Insurance

Forms

Premier Plan Forms:

• UHCSR Claim Form (PDF)
• Prescription Claim Form (PDF)
• HPV Vaccine Medical Claim Form (PDF)
• Medication Override Form (PDF)
• Prescription Extension Request Form
  To obtain prescriptions beyond the authorized 30 days when traveling outside of the United States.

Study Abroad Plan Forms:

• CMI/ACE American Co. Claim Form (PDF)
• CMI/ACE American Co. Claim Form Instructions (PDF)
• Study Abroad Waiver Form (PDF)
  Students enrolled in Office of International Programs' Courses, Main Campus, are required to purchase the Study Abroad Plan, without the waiver option.

EFL Plan Forms:

• EFL Medical Claim Form (PDF)
• EFL RX Claim Form (PDF)