Forms

The following files are in PDF format:

• UHCS Access Request Form : This form is to be used by Graduate and CPS students that waive from NUSHP, but would like to have access to the University’s Health and Counseling Services.
• Mid Year Adjustment Form : This form is to end coverage of NUSHP. (*Only for students who Graduate in December or Exchange students who leave in Decemeber will be considered for the adjustment.) The deadline to submit the form is January 31, 2023.
• Mid Year Enrollment Form: This form is for students who wish to enroll in NUHSP during our open enrollment period. Coverage will start January 1, 2023. The deadline to submit the form is January 31, 2023.
• Petition to Enroll NUSHP – Student Only : Use this form is if you have had a qualifying event and are in need of insurance.
• Petition to Add Dependents : If you are already enrolled in NUSHP, but need to add a dependent.

Other Forms

The following files are in PDF format:

• BCBS Claim Form
• BCBS International Claim Form
• Fitness Benefit Fact Sheet
• Weight Loss Benefit Fact Sheet
• Prescription Drug Claim Form