GHC-SCW Out-of-Area Student Coverage Verification

GHC-SCW Out-Of-Area Student Coverage Verification
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Out-of-Area Full-Time Dependent Student Form
Out-of-Area Full-Time Dependent Student Form

Please fill out this form if your employer has additional coverage for out-of-area full-time student dependents and you have a dependent full-time student who will be attending a school or university outside of GHC-SCW's HMO service area.

You will be required to complete this form on an annual basis during your employer's open enrollment period. Please notify GHC-SCW if there are any changes to your dependent child's full-time student status or school location, or if your child has permanently relocated back inside GHC-SCW's HMO service area.

For assistance completing this form, please reach out to GHC-SCW’s Member Services Department at (608) 828-4853.
Submission Date*

MonthDayYear
Date
Policy Holder Name*

First NameLast Name
Policy Holder Member Number*
This can be found on your GHC-SCW member ID card.
Policy Holder Email*
example@example.com
Policy Holder Employer*
Student Dependent Name *

First NameLast Name
Student Dependent Member Number*
This can be found on your GHC-SCW Member ID Card.
Date of Relocation*

MonthDayYear
Date
Out-of-Area School or University Name*
School or University Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

GHC-SCW Out-Of-Area Student Coverage Verification