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Y5mZEoBXyLDE9ImNB64vVwsqUP8nxBKnajCwddBAqz6rdLTMbnEjcH7mPaJ3Z

Proof of Health Care Coverage, Compliance Form (2020-21)

Returning?

This form is designed to assist students in complying with the Virginia Commonwealth University School of Medicine policy, which mandates that all medical students shall have and maintain health insurance coverage. The policy sets forth the minimum insurance requirements for all enrolled medical students. Students must verify that the basic benefits outlined in the form are included in their health insurance policy and provide documentation that their policy provides those benefits necessary to meet the established requirements. If any of these benefits are not covered, a hold will be placed on the student’s account (registration) until proof of sufficient coverage is received in this office. This hold means that you cannot attend classes or participate in clinical activities, and you will not be eligible to receive financial aid. This form should be submitted by July 19th, 2020. Please allow at least 4-8 weeks processing time to confirm receipt.

INSTRUCTIONS TO STUDENTS

1) Please contact your insurance company and speak with an agent/representative to review and assist in the completion of the form. In order for a policy to be considered compliant, the questions contained on the form should receive a response of “Yes”

2) Please request a Certificate of Coverage from your insurance agent/representative. The certificate should be submitted with the form. The certificate should contain the following information:

Date of the Certificate
Name of Health Plan
Name of the Participant
Identification Number of the Participant
Name(s) of the Covered Dependent(s) to whom this Certificate applies
Plan Administrator (include name, address and telephone number)
Date Waiting Period (if any) began
Date Coverage began
Date Coverage will end

3) A health Insurance card is not considered an acceptable form of Proof of Health Care Coverage.

4) Please return all information (including verification of coverage letter) on one PDF.

Christal L. Schools
Administrative Support Coordinator
Virginia Commonwealth University - School of Medicine Division of Student Affairs
1201 E. Marshall Street, 4th Floor, Suite 200
PO Box 980565
Richmond, VA 23298

If you have difficulty uploading to PDF format, you may either fax the information to (804) 828-5115 or email Christal.Schools@vcuhealth.org.

For additional questions regarding the compliance policy and/or procedures, please contact either Christal L. Schools, 804.827.1260 or Audrey Manley, 804.828.0998. The number for the University Student Health Services office is (804) 828-8828.

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M-D-Y

By providing my signature below, I hereby permit my health care insurance company to release and/or verify, either in writing, by fax, by telephone and/or by email, information to staff at Virginia Commonwealth University, School of Medicine "VCU, SOM" regarding my health plan coverage. I understand that insurance policies are approved for limited time periods and that the requirements of VCU, SOM are subject to change. I further understand that I must have my insurance policy re-certified annually, prior to each fall term registration.

Provide Signature for Release of Information here:

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Add signature

M-D-Y

I understand that if my policy does not meet all requirements, this does not mean that VCU School of Medicine, or any of its staff or faculty, recommend that I should cancel or let expire any existing, pending or proposed insurance coverage. A denial only implies that the policy presented does not meet the minimum criteria established by VCU with respect to specific medical insurance criteria required for all medical students.

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M-D-Y

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