Get Waiver Appeal Form (pdf) - University Health Services
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How to fill out the Waiver Appeal Form (PDF) - University Health Services online
This guide provides clear and concise instructions on completing the Waiver Appeal Form for University Health Services. Follow the steps carefully to ensure that your appeal is submitted accurately and timely.
Follow the steps to fill out your Waiver Appeal Form online.
- Press the ‘Get Form’ button to access the Waiver Appeal Form and open it for editing.
- Begin by filling out Section A: Student Information. Indicate your status by selecting the appropriate checkbox (e.g., New Undergraduate, Continuing Graduate) and provide your last name, first name, middle initial, current address, city, state, zip code, student ID, date of birth, confirmation number, telephone number, and email address.
- Select the academic year and term of appeal that applies to you, ensuring the selection aligns with the current term.
- In the space provided, clearly describe the nature of your request and the circumstances surrounding your appeal. Be as detailed as possible; you can use additional space on the back of the form if necessary.
- Attach a copy of your insurance card (both front and back) as well as the statement or summary of benefits from your health insurance plan. If you are submitting an international plan, include a copy of the entire policy written in English and in US dollars.
- Review your completed form for accuracy, ensuring all necessary fields are filled out. Sign the form where indicated to attest that the information provided is accurate.
- Submit your completed form and all required documentation to the Student Health Insurance Office at the specified address, or via fax or email as indicated.
Complete your Waiver Appeal Form online today to ensure timely processing of your appeal.
Rutgers Student Health (RSH) accepts all insurance plans for fulltime students. Students with NJ State Medicaid or NJ Family Managed Care Policies will receive basic healthcare at Rutgers Student Health but may need to be referred back to their primary care physician for certain immunizations, procedures, or referrals. Insurance & Costs - Student Health - Rutgers University Rutgers Health Services https://health.rutgers.edu › insurance-costs Rutgers Health Services https://health.rutgers.edu › insurance-costs
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