Dependent Enrollment Forms

Students may enroll their eligible dependents in the program by submitting an enrollment form and paying the applicable Student Health Services access fee within thirty one (31) days of a qualifying event as defined below. The access fee will depend on the eligible dependents the student chooses to enroll.

Required documentation

Appropriate documentation for each family member enrolled in the student’s plan is required.  Documentation is required only for initial enrollment (unless there is a change in your dependent’s information or are enrolling a dependent due to a life changing event).

  • Spouse: Marriage certificate, proof of joint residency
  • Qualified same-sex partner: Proof of joint residency
  • Dependent children: Birth certificate, legal documentation of adoption or guardianship, proof of residency
  • Other health insurance coverage ending: Copy of insurance termination of coverage letter

Benifits Domestic Partner Verification

Benifits Dependent Verification Affidavit

Benefits Dependent Enrollment

Prepaid packet with app