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Student Health Plan Waiver

BYU-Idaho requires all traditional, matriculating students to either have health insurance coverage in the Rexburg, Idaho area, or participate in the BYU-Idaho Student Health Plan for the duration of their BYU-Idaho education (including, but not limited to, semesters during which you are off-track, deferred, suspended, or completing an internship).  If you have selected the Student Health Plan by mistake, or were unable to enter your private insurance information online, the Health Plan can be waived if the waiver is received by the semester deadlines.

Insurance that is accepted to waive the Student Health Plan:

  • Insurance through a policy held by a parent
  • A group insurance plan provided by your employer or your spouse’s employer
  • FULL Coverage Idaho Medicaid or Medicare
  • Affordable Care Act compliant health care plan that is valid in Idaho

Insurance that is NOT accepted to waive the Student Health Plan:

  • Short term, travel, or international policies
  • Policies that provide only emergency and urgent care in the Rexburg, Idaho area
  • Medicaid from any other state than Idaho

Your coverage must provide full medical care if you are living in the Rexburg,Idaho area.  MOST STATE FUNDED PLANS WILL ONLY OFFER EMERGENCY COVERAGE OUTSIDE OF THEIR STATE OF RESIDENCE AND WILL NOT QUALIFY FOR THE WAIVER, if the student resides in the Rexburg, Idaho area.

Instructions:  To waive your enrollment in the Student Health Plan, complete and submit this form.  It must be received by the end of the first week of the semester or your student account will be charged for the Student Health Plan contribution and will NOT be refunded.

I hereby authorize BYU-Idaho to contact the insurance company that I provided to verify my coverage. This authorization expires when I have completed my education at BYU–Idaho, when the selected semester is over or when I cancel this waiver in writing.  I understand that if the policy listed above will not fully cover me in Idaho, this waiver will not be accepted and the Student Health Plan will not be removed.

Last Modified:  September 1, 2020

 

September 28, 2020

Please select who will be participating...
AdultMinor
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First Student Name

First Name*

Middle Name

Last Name*

Phone*
First Student Date of Birth*
I certify that I am 18 years of age or older
First Student Health Insurance Information
I HAVE FULL INSURANCE COVERAGE IN THE REXBURG, IDAHO AREA. *
Yes
THIS WAVIER APPLIES TO ONLY ONE SEMESTER. PLEASE SELECT THE SEMESTER TO BE WAIVED. *
Fall
Winter
Spring
Summer
PLEASE SELECT THE APPROPRIATE TYPE OF POLICY UNDER WHICH YOU ARE COVERED: *
Insurance through a policy held by a parent.
Group insurance coverage provided by your employer or your spouse's employer.
Off-track. Have coverage outside the state of Idaho.
Affordable Care Act compliant health plan with coverage in Idaho.
Medicare or Idaho Full Coverage Medicaid (Pregnancy-related Medicaid coverage will NOT be accepted. Notice of Action letter is required for Idaho Medicaid. Email letter to healthcenterbilling@byui.edu.

Policy Number *

Group Number *

Amount of Plan Deductible *

Policy Holder's Name *

Policy Holder's Birthdate *

Policy Holder's Address (not the participant's address) *

Insurance Company Name *

Insurance Company Claim Phone Number *

Insurance Company Claim Address *
First Student Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Student's I-number

Enter I-number (do not use spaces or dashes - example: 222222222) *
I agree to the terms of the above Student Health Plan Waiver on behalf of Minor.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Health Insurance Information
I HAVE FULL INSURANCE COVERAGE IN THE REXBURG, IDAHO AREA. *
Yes
THIS WAVIER APPLIES TO ONLY ONE SEMESTER. PLEASE SELECT THE SEMESTER TO BE WAIVED. *
Fall
Winter
Spring
Summer
PLEASE SELECT THE APPROPRIATE TYPE OF POLICY UNDER WHICH YOU ARE COVERED: *
Insurance through a policy held by a parent.
Group insurance coverage provided by your employer or your spouse's employer.
Off-track. Have coverage outside the state of Idaho.
Affordable Care Act compliant health plan with coverage in Idaho.
Medicare or Idaho Full Coverage Medicaid (Pregnancy-related Medicaid coverage will NOT be accepted. Notice of Action letter is required for Idaho Medicaid. Email letter to healthcenterbilling@byui.edu.

Policy Number *

Group Number *

Amount of Plan Deductible *

Policy Holder's Name *

Policy Holder's Birthdate *

Policy Holder's Address (not the participant's address) *

Insurance Company Name *

Insurance Company Claim Phone Number *

Insurance Company Claim Address *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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