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Forms (enroll, waive, cancel)

Insurance coverage periods are August 1 through July 31 each year.

Eligibile participants may enroll. Deadlines and conditions for enrollment apply and are enforced.

Fall insurance enrollments and waivers:

All eligible students 18 years of age or older are expected to enroll or waive using Student Information Online. Forms are available under the Campus Life/Health Insurance tab, and are available in early may each year. We anticipate them being available May 6 this year.

Eligible participants less than 18 or without access to the Student Information System should email the Student Insurance Office for a printable version [pdf] of the full-year enrollment or waiver form.

Enrollments and waivers outside of the fall open enrollment period are all done in hardcopy.

Hardcopy enrollment forms

Prorated forms for CURRENT insurance year (August 1, 2012 through July 31, 2013):

Prorated forms for the FUTURE insurance year (August 1, 2013 - July 31, 2014):

August 1 2013 - August 31, 2013 [pdf] August only
September 1, 2013 - July 31, 2014 [pdf]
October 1, 2013 - July 31, 2014 [pdf]
November 1, 2013 - July 31, 2014 [pdf]
December 1, 2013 - July 31, 2014 [pdf]
January 1, 2014 - July 31, 2014 [pdf]
February 1, 2014 - July 31, 2014 [pdf]
March 1, 2014 - July 31, 2014 [pdf]
April 1, 2014 - July 31, 2014 [pdf
May 1, 2014 - July 31, 2014 [pdf]
June 1, 2014 - July 31, 2014 [pdf]
July 2104 only [pdf]

Hardcopy waiver form

If you are a student 18 years of age or older, and it is the fall open enrollment period, please access the online waiver from through Student Information Online. Details on access are found above.

Otherwise, email the Student Insurance Office to request a hardcopy waiver form.

August graduates may enroll only for the month of August

August graduates are permitted to enroll for August only in the new insurance year, and should complete the hardcopy August-only form found in the "Hardcopy enrollment forms" above.

Enrollment across insurance years

If you are enrolling in the insurance mid-year, say June, and wish to also be enrolled after July 31 when the current insurance year ends, you will have to complete two forms: one for the current year's coverage running June 1 - July 31, and one for the coming year for coverage starting August 1. Remember: prior year enrollments don't roll-over to the next year.

Modify or cancel your enrollment decisions

Review the enrollment opportunities and deadlines that apply to enrollment changes.

Vision and dental enrollment decisions cannot be cancelled. If you enrolled yourself in the fall open enrollment period, and wish to enroll a spouse, domestic partner or children in the Spring, you have to pay the entire additional premium. There is no proration, and a change in enrollment is treated as another enrollment entirely.

Medical enrollment decisons can be modified when qualifying events take place, and require that a medical enrollment change form be completed.

Medical enrollment decisions can be cancelled if 1) the cancellation is done before April 1, and 2) no claims are paid or pending against the policy. A medical enrollment cancellation form is required. Students who must meet the university's insurance requirements must also complete a waiver form.

Remember: vision and dental are available only in the fall and spring open enrollment periods

Eligible participants can enroll in vision and dental only during the fall and spring open enrollment period, so vision and dental appear only on the full-year and January enrollment forms each year.

Questions? Contact your Student Insurance Office.

Forms (enroll, waive, cancel)-University Health Services - Carnegie Mellon University

Carnegie Mellon University

Forms (enroll, waive, cancel)

Fall insurance enrollments and waivers:

Enrollments and waivers outside of the fall open enrollment period are all done in hardcopy.

Hardcopy enrollment forms

Prorated forms for CURRENT insurance year (August 1, 2012 through July 31, 2013):

Prorated forms for the FUTURE insurance year (August 1, 2013 - July 31, 2014):

Hardcopy waiver form

August graduates may enroll only for the month of August

Enrollment across insurance years

Modify or cancel your enrollment decisions

Remember: vision and dental are available only in the fall and spring open enrollment periods

Student Medical Insurance policy and insurance requirements.