MGH INSTITUTE OF HEALTH PROFESSIONS
Student Health Insurance Plan

2016-2017 Spring Term Enrollment Form


This enrollment form is for New Degree/Certificate Students for the Spring 2017 Term.

The enrollment deadline date for Spring Semester is December 31, 2016.


(Enrollment Period of 01/01/17-04/30/17)

NOTE:  If you will graduate in September of 2016, this coverage will be effective until August 31, 2016.  If you will graduate in January of 2017, this coverage will be effective until December 31, 2016.

 

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number: *
date of birth: * (MM/DD/YYYY)