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Proof of Health Care Coverage, Compliance Form (2021-22)

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 August 31, 2021. Please allow at least two weeks processing time to confirm receipt.

INSTRUCTIONS TO STUDENTS

Contact your insurance company, speak with an agent/representative to review your policy ensuring compliance; all questions contained on the form should receive a response of “Yes.
Also request a Certificate of Coverage from your insurance agent/representative. The certificate is to be submitted with the form. Note: A health Insurance card is not considered an acceptable form of Proof of Health Care Coverage. The Certificate should contain the following information:
1. Date of the Certificate
2. Name of Health Plan
3. Name of the Participant
4. Identification Number of the Participant
5. Name(s) of the Covered Dependent(s) to whom this Certificate applies
6. Plan Administrator (include name, address and telephone number)
7. Date Waiting Period (if any) began
8. Date Coverage began
9. Date Coverage will end

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

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

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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.

Provide Signature of Understanding here:

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Add signature

M-D-Y

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