If your insurance waiver has been denied and you would like to appeal the decision, please fill out and submit this form.
Instructions on how to appeal your Health Insurance Waiver denial:
Appeals will not be reviewed until this information is received via fax: 888-471-2290, email: email@example.com, or in person: UC 5th floor. Once all the necessary information is received you will receive a decision on your appeal within 3-4 business days.
The form below is not a health insurance waiver form. This form is intended only for students that have had their initial insurance waivers denied and would like to appeal the denial. Please contact HPS at 415-422-5797 if you have questions before completing this form.
Insurance Company Name:
Policy or Group Number:
Please explain the reasons for the appeal:
2130 Fulton Street
University Center, Fifth Floor
San Francisco, CA 94117
Hours: 8:30am to 5:00pm
Tel: (415) 422-5797 Fax: (888) 471-2290Email: firstname.lastname@example.org