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eYPTmi6qFCgJPQibrsHmdTXAD5WQDrmyg5t7pGDd7XMe4tQmfyphB5

Proof of Health Care Coverage, Compliance Form (2019-20)

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This form is designed to assist students in complying with the Virginia Commonwealth University School of Medicine policy (refer to the Student Handbook), which mandates that all medical students shall have and maintain health insurance coverage. The Compliance Form sets forth the minimum insurance requirements for all enrolled (including newly 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 offers 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. Please allow at least 6-8 weeks processing time to confirm receipt. Submission deadlines are as follows:

M1 students (new enrollees): 0719/19
M2, M3 & M4 students: 08/31/19

INSTRUCTIONS TO STUDENTS

1. Please contact your insurance company and speak with an agent/representative to review and assist in the completion of section II of this 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 Group and/or Individual Health Plan Coverage from your insurance agent/representative. The Certificate should be submitted as part of section III of this form. The certificate should contain the following information:

a. Date of the Certificate

b. Name of Health Plan

c. Name of the Participant

d. Identification Number of the Participant

e. Name(s) of the Covered Dependent(s) to whom this Certificate applies

f. Plan Administrator (include name, address and telephone number)

g. Date Waiting Period (if any) began

h. Date Coverage began

i. Date Coverage will end

3. A health Insurance card WILL NOT BE CONSIDERED an acceptable form of Proof of Health Care Coverage.

If you have any additional questions or need assistance with regard to this compliance policy, please contact the VCU School of Medicine Student Affairs Office at (804) 827‐1260 or via email at SOMHealthIns@vcuhealth.org.

Student's Full Name:

* must provide value

Please provide V Number here:

Class of:

* must provide value

Note: M1, first year. Your insurance must be submitted by July 19th, 2019.

Note: M2, M3, M4 & PhD year. Your insurance must be submitted by August 31st, 2019.

If other, please explain:

Permanent Street Address:

* must provide value

City:

* must provide value

State / Province:

* must provide value

Country:

* must provide value

Zip Code:

* must provide value

Student Phone Number:

* must provide value

Student Email Address:

* must provide value

My plan is provided by a company licensed to do business in the United States, with a U.S. claims payment office and a U.S. phone number.

* must provide value

Yes No

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Please explain why you've selected "No" here:

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My plan offers coverage per injury or sickness in the Richmond, VA area (including hospitalization, surgery, mental health, medical equipment, pregnancy, and physical exams.)

Note: Coverage for emergency-only care does not satisfy this requirement. Catastrophic and short term policies do not qualify.

* must provide value

Yes No

reset

Please explain why you've selected "No" here:

* must provide value

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My plan provides prescription drug coverage.

* must provide value

Yes No

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Please explain why you've selected "No" here:

* must provide value

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My plan is currently active, and I agree to maintain health insurance coverage throughout the entire 2019 / 2020 academic year.

Note: If your coverage ends prior to July 31, 2020, then you must provide proof that you are leaving the university before your insurance expires.

* must provide value

Yes No

reset

Please explain why you've selected "No" here:

* must provide value

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My plan provides coverage for pre-existing conditions.

* must provide value

Yes No

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Please explain why you've selected "No" here:

* must provide value

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Health Insurance Company's Name:

* must provide value

If other, please provide Health Insurance Company name here:

* must provide value

Type of Health Insurance provided by Aetna:

* must provide value

Type of Health Insurance provided by Anthem Blue Cross Blue Shield:

* must provide value

Type of Health Insurance provided by CIGNA:

* must provide value

Type of Health Insurance provided by Coventry:

* must provide value

Type of Health Insurance provided by United HealthCare:

* must provide value

If other, please provide type of Health Insurance here:

* must provide value

Please provide Health Insurance Company's Street Address, City, State, and Zip Code:

* must provide value

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Health Insurance Company's Phone Number:

* must provide value

Health Insurance Policy and/or ID Number:

* must provide value

Are you the Policy Holder for the Health Insurance Policy given above?

* must provide value

Yes No

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Health Insurance Policy Holder's Name:

* must provide value

Health Insurance Policy Holder's Relation to Student:

* must provide value

Do you have a copy of the Certificate of Group and/or Individual Health Plan Coverage available for attaching / uploading to this form? Click here to see an example.

* must provide value

Yes No

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Please attach / upload a copy of the Certificate of Group and/or Individual Health Plan Coverage. Click here to see an example.

* must provide value

Upload file

If you do not have a copy of the Certificate of Group and/or Individual Health Plan Coverage available for attaching / uploading to this form, please explain why here.

* must provide value

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By signing below, I affirm that I have verified the information above to be true and correct, and I hereby certify that the health care coverage indicated above is current and currently in force.

Provide Signature for Compliance of Health Care Coverage here:

* must provide value

Add signature

Date of Signature:

* must provide value

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:

* must provide value

Add signature

Date of Signature:

* must provide value

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:

* must provide value

Add signature

Date of Signature:

* must provide value

M-D-Y

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