Simmons University

Undergraduate Student Health Insurance Plan 
Annual Enrollment Form 
August 15, 2019 - August 14, 2020


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

Please note if you just registered for classes you will have to wait a week to complete the form. Simmons University updates the authorization list for access to the forms once a week.

**The MassHealth Premium Assistance (MHPA) Program is no longer available through Simmons University for the 2019-2020 academic year. MassHealth will no longer pay for the Simmons University Blue Cross Blue Shield Student Health Plan for MassHealth members. By completing this enrollment form you are confirming you would like to be enrolled in the Student Health Insurance Plan and understand you will be responsible for paying the premium.**

 (MM/DD/YYYY)