Health Insurance Waiver Form for Tufts Universitys Boston and Grafton Campuses 2018-2019-2025

1. Click ‘Get Form’ to open the Health Insurance Waiver Form in the editor.
2. Begin by indicating your school from the options provided: Dental, Medical, Nutrition, Public Health Programs, or Veterinary.
3. Fill in your personal information including your name (last, first, middle), Tufts ID, address, date of birth, gender, and email.
4. Answer the five questions regarding your insurance coverage by selecting 'Yes' or 'No' for each question related to services provided in Massachusetts.
5. Provide details about your insurance company including its name and policy number. Also include the state of the insurance company and the policyholder's name along with their relationship to you.
6. Read and understand the certification statement regarding your responsibility for medical expenses before signing and dating the form.
7. If applicable, complete the cancellation section for HPHC/UHCSR coverage by providing a cancellation date and signing it.
8. Finally, return the completed form via email to Cynthia.Linton@tufts.edu or send it to the Student Advisory & Health Administration Office at Tufts University.

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