Bridgewater State University
Student Health Insurance Plan
MassHealth Premium Assistance Request Form

2016-2017 Policy Year

To see if you’re eligible for MassHealth Premium Assistance to pay for your enrollment in the Student Health Insurance Plan (SHIP) effective 1/1/17, you must submit this Request Form by the deadline of 2/28/17. Within, approximately, 5-15 business days you will receive an email from University Health Plans letting you know the results of your request.
 

If your request is approved:

  • the SHIP charge on your student account will be waived;
  • you will be enrolled in the SHIP through Blue Cross Blue Shield;
  • you will receive a Blue Cross Blue Shield insurance card in the mail; and
  • your coverage under MassHealth will be unaffected by the SHIP enrollment.


If your request is rejected or declined, you may be allowed to resubmit this form.


To continue this request process, provide the information below. You will need your 12-digit identification number from your MassHealth card for the next page of this form.

If you do not want to continue this request process and would prefer to submit the normal Waiver Form or Enrollment Form, please select the appropriate link from the menu on the left. 
 


COMPLETE THE FIELDS BELOW TO CONTINUE:

Date of Birth:  (MM/DD/YYYY)
Banner ID: