MCPHS University
STUDENT HEALTH INSURANCE PLAN

2022-2023 Academic Year
Spring Dependent Enrollment Form
 

Dependent coverage, if elected, begins and ends with the student’s coverage and must be purchased at the same time the student enrolls in the plan.

The deadline to complete the Spring Dependent Enrollment Form is December 1, 2022.


TO CONTINUE THE DEPENDENT ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Asterisk (*) denotes required field

STUDENT INFORMATION

 (MM/DD/YYYY)