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UCLA Health Insurance Waiver Form

This document is a health insurance waiver form from UCLA Extension's International Student Office. It explains that F-1 international students are required to have adequate health insurance while enrolled. Students can purchase the school's insurance or provide their own by signing a waiver. Any alternate insurance must be from a US-based company and provide comprehensive coverage and access to local providers. By signing, a student acknowledges responsibility for maintaining valid insurance for the duration of their F-1 student status.

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286 views1 page

UCLA Health Insurance Waiver Form

This document is a health insurance waiver form from UCLA Extension's International Student Office. It explains that F-1 international students are required to have adequate health insurance while enrolled. Students can purchase the school's insurance or provide their own by signing a waiver. Any alternate insurance must be from a US-based company and provide comprehensive coverage and access to local providers. By signing, a student acknowledges responsibility for maintaining valid insurance for the duration of their F-1 student status.

Uploaded by

lalith
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

UNIVERSITY OF CALIFORNIA, LOS ANGELES UCLA

BERKELEY  DAVIS  IRVINE  LOS ANGELES  MERCED  RIVERSIDE  SAN DIEGO  SAN FRANCISCO SANTA BARBARA  SANTA CRUZ

UCLA EXTENSION
INTERNATIONAL STUDENT OFFICE
1145 GAYLEY AVENUE, 2ND FL
LOS ANGELES, CALIFORNIA 90024
(310) 825-9351

HEALTH INSURANCE WAIVER FORM


Policy for F-1 International Students who have their own health insurance

As a condition of enrollment at UCLA Extension, all F-1international students are required to have
adequate medical insurance coverage while in F-1 status. UCLA Extension also requires medical
insurance for dependents (F-2 visa holders).

UCLA Extension makes a health insurance policy available for you to purchase every quarter. We have
identified a policy that provides you with the most comprehensive coverage at the best price.

If you do not purchase our insurance, please be aware that the insurance you purchase may not provide
the same level of coverage. Please note that we cannot help you in your search for a health insurance
company. If you have any questions, please contact the alternate health insurance company directly if
they meet the qualification below.

To qualify, the medical insurance plan you purchase:

Must be a medical/health insurance plan purchased in the U.S. with a U.S.-owned


insurance company that is headquartered and operating in the U.S.

It must not be foreign insurance with U.S. affiliates/representatives, travel insurance, or


reimbursement programs of any kind. These are not acceptable. This includes
reimbursement arrangements of vouchers from home governments or their U.S. based
consulates.

If you choose to purchase your own health insurance plan, please do the following:

1. Sign the statement below and return this form to the International Student Office

2. Submit a copy of your health insurance card (front and back) or policy showing your full
name and the coverage dates.

3. Submit a list of your health insurance company’s preferred provider network of local
hospitals.

Statement: I understand that I am fully responsible for my own medical/health insurance coverage
during the entire period that I am an F-1 international student at UCLA Extension.

I also understand that I will be responsible for renewing my health insurance if it expires while I am
still in F-1 visa status.

FAMILY NAME: _____________________________ FIRST NAME: _______________________

SIGNATURE: ________________________________ DATE: _____________________________

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