Health Insurance Release Form printable pdf download

Health Insurance Release Form

for Dependents of F-1 students

I __________________________________________________, SCSU ID# _______________________

(print full name)

plan to bring the following dependents to join me in St. Cloud, MN:

Dependent 1: _______________________________________ [ ] Spouse [ ] Child

Name

Dependent 2: _______________________________________ [ ] Child

Name

Dependent 3: _______________________________________ [ ] Child

Name

Dependent 4: _______________________________________ [ ] Child

Name

Select one:

[ ]

I plan to enroll my dependent(s) in the MnSCU Health Insurance plan administered by Health

Services at St. Cloud State University. The charge for a spouse (if applicable) is $2,752/year and

the charge for each child (if applicable) is $1,693/year. I understand that I must contact the

Center for International Studies annually to continue health insurance coverage for my

dependents.

[ ]

I do not plan to enroll my dependent(s) into the MnSCU Health Insurance plan. I understand that

as an F-1 student, I am not required to purchase the MnSCU Health Insurance for my

dependent(s).

I will be responsible for all medical and/or dental costs while they are in the United States

should we not purchase MnSCU Health Insurance. Under no circumstances is St. Cloud

State University responsible for any medical and/or dental costs that my dependent(s) incur

while in the United States.

I have read and understand the above statement.

_____________________________________________________

___________________

Student Signature

Date

Reviewed/Approved by Special Advisor to the President, 12/19/2008

Center for International Studies, Lawrence Hall 101, 720 Fourth Ave South, St Cloud, MN 56301

Phone: 320-308-4287 / Fax: 320-308-4223 / Email: isss@stcloudstate.edu

9/2010

Health Insurance Release Form