PINE MANOR COLLEGE
STUDENT HEALTH INSURANCE PLAN

2017-2018 POLICY YEAR
SPRING WAIVER FORM

Students who are eligible to be charged for the Student Health Insurance Plan but have other comparble coverage may decline the PMC plan by completing this waiver form. Requirements of compable coverage include:

  • a plan from a US based carrier;
  • comprehensive coverage in the Boston area for hospital care (inpatient and outpatient), physician services, mental health services, lab/x-ray/diagnostic services, and prescription drug coverage;
  • comprehensive coverage for the services indicated above in both emergency and non-emergency situations; and
  • a deductible, if any, of no more than $250.

Please Note: Health Safety Net, MassHealth Limited, and Children's Medical Security Plan may not be used to waive participation in the Pine Manor College Student Health Insurance Plan.


The deadline to waive the PMC plan is February 9, 2018.

Students who do not submit a waiver form will be enrolled in the PMC plan and responsible for the premium charged to their student accounts.

Should you have questions about the waiver, please contact University Health Plans at info@univhealthplans.com or 800-437-6448.


If you have determined your plan to be comparable, please fill in the fields below to continue:

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)