Health Insurance Waiver Form

FirstName:
Last Name:
Middle Initial:
Date of Birth:

*Acceptable Alternative Insurance Plans

Only plans meeting the following conditions are acceptable alternative plans that satisfy the University's requirements for student health insurance:

• "Comprehensive" (major medical) individual policy providing at least $500,000 coverage;
• Health Maintenance Organization (HMO) with locations in Maryland or;
• "Comprehensive" Employer sponsored/Union sponsored plan, or;
• Plan sponsored by the United States Government.

When I waive purchase of the Student Health Insurance Plan, I understand that this means I WILL BE RESPONSIBLE FOR ANY MEDICAL EXPENSES WHICH I MAY INCUR. I am waiving purchase of the health insurance plan offered by Johns Hopkins University, School of Nursing, and I certify that I have EQUIVALENT OR BETTER* coverage through the following:

Insurance Company:
Insurance Co.'s Address:
Insurance Co.'s Phone #:
Your Policy ID#:
Effective Date:

Optional:
Student may obtain services from University Health Services for an annual fee of $250.00.

I have read the information describing the health insurance plan offered through The Johns Hopkins University, School of Nursing, and have elected to WAIVE THE PLAN.