STUDENT MEDICAL INSURANCE CANCELLATION FORM
Use this form to cancel your student medical insurance. Please complete all fields.
Questions? Visit www.cmu.edu/health-services/student-insurance for insurance info and instructions on scheduling appointments, email shinsure@andrew.cmu.edu, or call 412 268 2157 and select the option for insurance.
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REVIEW THE STUDENT MEDICAL INSURANCE CANCELLATION POLICY *


With this form, you are requesting that the student medical insurance for you and all of your enrolled dependents be cancelled. If instead you wish to cancel only specific dependents, please complete a STUDENT MEDICAL INSURANCE CHANGE OF ENROLLMENT form.
You, the policy holder, must remain enrolled in the medical insurance if you wish to have any dependents enrolled. If you are still a full-time Carnegie Mellon student, you must also complete an insurance WAIVER form.
You may be eligible for a prorated refund. Our insurance enrollment year begins August 1 each year, and continues through July 31. If you cancel your student medical insurance before April 1 within that enrollment year, and if the insurance company has not paid any claims for you (prescriptions, doctor visits, emergency room visits, etc.), then you are eligible for a pro-rated refund. If claims later surface, you can be recharged for any previously refunded premium. These conditions hold true for any dependents you wish to cancel. You cannot cancel insurance for yourself if one of your dependents remains enrolled.
The premium costs for insurance include a yearly processing fee. This processing fee is not refunded.When your insurance is cancelled, your student account is credited with 1/12 of the remaining premium for each of the months left in the enrollment period.
If a refund is appropriate, it will be posted to your Student Account. Your cancellation date is the last day of the month following the later of these two dates: Completion date if one was specified, or the date on which University Health Services receives your completed form. Cancellations will be processed 15 days after the cancellation date. Your credit will be posted within ten business days of processing.  If the insurance refund results in a credit balance on your account, contact the HUB (412-268-8186) for instructions on how to obtain those funds. If you do not have a Student Account, we will be contacting you to confirm how you will receive your credit.
If you utilized Tuition Management Systems (TMS) to set up a monthly payment plan for insurance premiums, you must also notify TMS (1-800-722-4867) to cancel your payment contract. That is not done automatically; you must contact TMS to cancel your contract.
Dental and vision plans are separate from the medical insurance plan. Those plans cannot be cancelled for any prorated refund of premium. This form cancels your student medical insurance only.
     
 
Last Name *

 
First Name *

 
Date of Birth *

 
Address

(Please include street address or SMC box, city, state and zip code)
 
9-digit Carnegie Mellon Student Account # *

(9-digit number beginning with the number 8)
 
Phone Number

 
Aetna Medical ID Number (this is printed on your Aetna insurance card)

If you don't have it, we will find it for you.
 
I am cancelling my student medical insurance because (select one): *


 
Completion Date: *

For graduating students, your completion date is when your graduation requirements were met.
For students submitting a waiver, your completion date the 1st of the month after your waiver is submitted.
For visiting researchers, exchange students and enrolled students, your completion date is the date you left the university.
 
Electronic Consent *

I have read the STUDENT MEDICAL INSURANCE CANCELLATION POLICY. I wish to cancel my student medical insurance. I have not used my student medical insurance on or after August 1 of this insurance enrollment year, nor have my enrolled dependents.
If approved, cancellation is effective as of the first of the month following the later of these two dates: Completion date if one was specified above, or the date on which University Health Services receives my completed form.
All necessary documents must arrive before April 1 in the current insurance enrollment year if I wish to be considered for a prorated refund.
     
 
Note that if you utilized TMS, you must contact TMS at 1-800-722-4867 to update the amount of the contract if desired. Contact University Health Services for calculated amount.

Thank you. We will be in contact with you via email to let you know your cancellation has been completed. Please allow 7-10 business days.
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