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OFFICE OF INTERNATIONAL EDUCATION
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Form to Request a
Medical Insurance Waiver


WAIVER DEADLINE: June 4, 2018

  • Wichita State University policy requires all international students to have medical insurance that provides the same benefits as the Patient Protection and Affordable Care Act (PPACA), in addition to coverage for medical evacuation and repatriation.   See Section 8.08 of the WSU Policies and Procedures Manual.
  • The completion of this form does not guarantee that you will be granted a waiver.
  • Please submit this form one time only per semester.
  • You will be automatically charged for medical insurance unless you apply and qualify for a waiver by the above deadline.  NO EXCEPTIONS
  • For definitions of words commonly used in the American health insurance industry, please view our Glossary of Insurance Terminology.
  • If you have any questions before completing this form, please email:
    insurance.waivers@wichita.edu.

1)  Requested Semester for Waiver

 Summer Session 2018

2)  Family Name
3)  First Name
4)  WSU ID Number
5)  Date of Birth (MM/ DD/YYYY)
6)  Email Address
7)  Your Telephone Number
8)  Country of Citizenship
9)  Name of Your Insurance Company

10)  Visa Type

11)  VERY IMPORTANT:  In order to qualify for a
       medical insurance waiver, students MUST
       HAVE insurance coverage which meets or
       exceeds ALL of the requirements below.
       You will be required to submit documentation
       from your insurance company that proves that
       your medical insurance:
       A)  Provides the same benefits as the Patient
             Protection and Affordable Care Act
             (PPACA).  
       B)  Minimum coverage for repatriation of
             remains (return of body to home country
             in case of death) of $25,000 and
             medical evacuation to home country
             of $50,000. (This requirement does not
             apply to students on H-1B visas).
       C)  Coverage from the first day of the
              semester to the last day of the
              semester.

 

 

 

 

12)  In order to be considered for an insurance
        waiver, you must also submit evidence of
        coverage such as a copy of the insurance
        card, coverage confirmation or details of
        policy coverage.  

        All supporting documentation must be in
        English, provide coverage amounts
        in U.S. dollars, and have a U.S. address
        and telephone number for claims.


       You may submit evidence of your
        insurance coverage in one of the following
        ways:
        a)  Email the scanned documentation to
             insurance.waivers@wichita.edu
        b)  Deliver copies of your supporting
            documentation by visiting Student  
            Health Services located in Room 209
            Ahlberg Hall
       c)  Fax documentation to:
            (316) 978-3517
            ATTN:  Waiver
       d)  Mail the documentation to:
            Student Health Services
            Wichita State University
            1845 Fairmount Street
            Wichita, KS  67260-0092

 I understand that I will not be
        considered for a waiver until WSU
        receives evidence of my insurance
        coverage in English for 11A, 11B,
        and 11C.  I also understand that
        coverage amounts must be in
        U.S. dollars and the insurance
        company must have a U.S.
        address and telephone number
        for claims.

13)  I understand that I must submit this form
       EVERY SEMESTER in order to be
       considered for a waiver. 

 Yes, I understand

14)  I certify that all of the information I have
       entered on this form is accurate and true. 
       If this waiver is approved, I understand that
       I am legally responsible for any health or
       medical expenses incurred during my
       enrollment at Wichita State University and
       that Wichita State University will not be
       responsible for any of my health or medical
       expenses.  If I am denied an insurance
       waiver, I understand that I will be
       automatically charged for medical
       insurance.

 I agree


 
15)  Name of the Student Electronically Signing
       This Form

16)  Date Electronically Signed