Late Waiver Appeal

Late Waiver Policy (Fall 2014)

Students who fail to submit a health insurance waiver by the September 1st deadline may file a late waiver appeal by November 1st.  Decisions will be sent by email within 5-7 business days of receiving a complete waiver appeal. If your late waiver appeal is approved a $250.00  late wavier fine will be placed on your student account and you will receive a  full refund of the semester health insurance premium. If your late waiver appeal is denied you will have an opportunity to waive the USF-sponsored insurance plan the following semester.

In order to qualify for a late waiver appeal the effective date of your coverage must be prior to September 1st, and remain in effect for the remainder of the academic year. No Late Waiver Appeals will be accepted after November 1st.   

Late Waiver Appeal instructions:

  1. Fill out the form below completely, including full name, student ID, email address, and insurance information..
  2. Obtain a letter from your insurance provider stating the effective date of your policy. 
  3. Email supporting documents to hps@usfca.edu, fax to 888-471-2290, or submit in person  at University Center 5th floor. 

Late Waiver Appeal:

Your Name:      

Student ID:       

Email :              

Insurance Company Name: 

Policy or Group Number:    

 

My plan provides access to Medical Care (including primary care office visits, routine health examinations, and preventative care) within 20 miles of my school campus. City health insurance plans(i.e Healthy San Francisco, Contra  Costa County, ect) do not meet USF insurance requirements.

 

In the event I terminate or lose my current insurance coverage I agree to contact USF Health Promotion Services within 15 days of termination.

               

My annual deductible is $2500 or less.

                

My plan allows unlimited Doctor office visits(primary care visits) for medical and mental health conditions.

                

My plan covers hospital stay for all medical, surgical, and mental health/substance abuse conditions without limitations.

My plan has an annual out of pocket maximum of $6,350 (individual)/$12,700(family) or less.

                

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

                 

My plan will pay at least 80% of covered medical expenses (80/20 co-insurance).

                 

If you use the USF-sponsored insurance at any point in the semester  you are not eligible for a Late Waiver Request and your student account will be charged for the cost of the insurance.  

If your Late Waiver Request is approved a $250.00 Late Wavier Fine will be placed on your student account.    

         

Your Late Wavier Request will not be reviewed until all supporting documents are received by HPS (Steps 1-3 above).    

In the space below please provide a statement detailing the circumstances which led to the missed waiver deadline: