Graduate Student Health Insurance Enrollment Submission
Please submit your Graduate Student health insurance enrollment through this form.
I have a...
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Engagement Assistantship
Research Assistantship
Teaching Assistantship
Fellowship
Applicable Semester
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Spring 2025
Summer 2025
Fall 2025
Spring 2026
Fall 2026
Name of Fellowship
Student Name
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Legal First Name
Legal Last Name
UA ID
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Email
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example@example.com
Department
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Student Phone Number
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Area Code
Phone Number
Student Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Birthday
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Month
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Day
Year
Date
Student Biological Sex (Required by Insurance Company)
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Male
Female
Intersex
Residency
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Domestic
International
Payment Details
This information can be found on your offer information on the second page of your NextGen form. They are listed as "Exemption Code for Health Insurance" and "Detail Code for Health Insurance", respectively on the Graduate Assistantship Offer Letter AY 2024-2025. If you have a fellowship this information should be located on the bottom of the award letter.
Exemption Code
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Detail Code
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Optional notes
Upload your award letter
Upload Document:
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Browse Files
PDF files only
Cancel
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Memo Submission Agreements
I have reviewed the Graduate School Student Health Insurance page found here and understand that I need to enroll in health insurance with UHCSR
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I Agree
I understand that I am fully responsible for any balance due and/or any late fees that are accrued for failure to pay the balance by the fee payment deadline.
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I Agree
Submit
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