Waiver Denial Appeal

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:

  1. Fill out the form below completely, including full name, student ID, email address, and insurance information.
  2. Make a copy of your health insurance card
  3. Attach a summary of benefits and coverage (A summary of benefits and coverage list the benefits and exclusions within your plan)
  4. Attach verification of active insurance from your current insurance provider and submit to the Health Promotion Services office. (A verification can be obtained through contacting your insurance provider. The verification must state the effective date of your policy) 

Appeals will not be reviewed until this information is received via fax: 888-471-2290, email: hps@usfca.edu, 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. 

Your Name:      

Student ID:       

Email :              

Insurance Company Name: 

Policy or Group Number:    

Please explain the reasons for the appeal: