Forms

The following files are in PDF format:

• Midyear Enrollment form : Used to enroll during our open enrollment period which is in December and January of every academic year. (*form will be up December 1, 2022)
• 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 who Graduate in December or Exchange students: form will be up December 1, 2022)
• 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