Get Gahp Twin Citiesrochester Dept Authorization Form - Shb Umn

Completing the GAHP Twin CitiesRochester Department Authorization Form is essential for enrolling in the University-sponsored Graduate Assistant Health Plan. This guide provides clear instructions to help you fill out the form accurately and ensure the enrollment process runs smoothly.

Follow the steps to fill out the GAHP Twin CitiesRochester Dept Authorization Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In section A, provide your fellow or trainee information. Fill in your name (last, first, middle initial), date of birth, gender, and University of Minnesota ID number. Also, include your street address, city, state, ZIP code, daytime phone number, and UMN e-mail address. Indicate your graduate program and job class, then specify if the form is to pay for yourself as a fellow/trainee or for a dependent.
3. In section B, complete the payment information. Enter the account string (EFS number) to be charged for coverage. If applicable, provide the eight-digit project code for projects with a sponsored activity. Specify the amounts to be charged for each semester (fall, spring, summer) along with the corresponding periods covered.
4. In section C, fill in the department contact information. This includes the name of the individual authorizing the form, their campus address, daytime phone number, and e-mail address. Make sure to provide an actual signature, as electronic signatures are not permitted, and date the form.
5. Review all entered information for accuracy. Ensure all required fields are completed. It's advisable to keep a copy of the filled form for your records.
6. Once everything is verified, save the changes to the form. You may proceed to download, print, or share the form as needed.

Complete your GAHP Twin CitiesRochester Dept Authorization Form online today to ensure your enrollment in the health plan.