MGH INSTITUTE OF HEALTH PROFESSIONS
Student Health Insurance Plan

2016-2017 Spring Term Waiver Form

This waiver form is for New Degree/Certificate Students and will be good through April 30, 2017.

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

You must complete all pages of this waiver form in order to waive the Institute's Student Health Plan. Failure to successfully submit the waiver form by the deadline of December 31, 2016, will result in the following:

  • You will be enrolled in the MGHIHP Student Health Plan.
  • You will be responsible for paying the full semester premium.
  • Also, until you have paid the full semester premium:
    • you will not be allowed to register for future semesters;
    • your grades and transcripts will be held; and
    • access to your student record on IONLINE will be limited.

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number: *