Ithaca College
STUDENT HEALTH INSURANCE PLAN

2017-2018 POLICY YEAR
Spring Opt-Out Request Form

Ithaca College requires all matriculated undergraduate and graduate students to have health insurance. All students who are required to have health insurance are initially charged for the SHIP. .

Eligible students who have other health insurance coverage (i.e. under a parent’s or employer’s plan) and do not want to be enrolled in the student health insurance plan must submit an online waiver documenting their other coverage prior to the posted deadline each academic year.Students who miss the waiver deadline will be enrolled in the student health insurance plan and held responsible for paying the associated premium.

The waiver deadline was August 31, 2017. This is the Spring Opt-Out Request Form. Completing this form does NOT guarantee that the spring insurance charge will be removed from your student account. You will receive an email in approximately 2-3 weeks stating whether your request has been approved.  Please note that if any claims were filed and paid under the Ithaca College Student Health Insurance plan during the Fall 2017 Term, the Spring Opt-Out Request will not be approved.


TO CONTINUE THE SPRING OPT-OUT REQUEST PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Please Note: You must enter your Ithaca College email address below. Entering your personal email address will not allow you access to the waiver form. You must activate your Ithaca College Netpass/e-mail account prior to completing this process.

date of birth: (MM/DD/YYYY)
student ID:
email address: