**THIS PAGE IS NOT NEEDED, GO TO MYUTH TO COMPLETE THE HEALTH INSURANCE CERTIFICATION**

Texas Education Code Section 51.961 authorizes a governing board to require health insurance of students enrolled in health institutions.  The University of Texas System, Board of Regents voted November 8, 2001, to include this requirement beginning with the 2002 – 2003 Academic Year.

Students are automatically assessed an insurance charge to their student fee bill for United HealthCare Insurance.  To waive this fee you are required to show proof of current health insurance coverage through another provider by completing the information below before the twelfth day of class for the Fall/Spring semester and the fourth day of class for the Summer semester of every academic year.  Failure to provide this information before the deadline will result in forfeiting your option to waive the health insurance coverage and associated fee.  Please note that it is not necessary to submit the waiver every semester, as after submitting the waiver in the fall and/or spring semester, the insurance fee will be removed from your bill for the remaining academic year.  Please do not complete this form if you are purchasing United HealthCare Insurance as assessed on your student fee bill. 

International students must have Repatriation/Evacuation coverage in addition to your health insurance coverage, if you are not purchasing United HealthCare Insurance.  An annual fee of $75 will be added to your student fee bill unless other coverage is indicated below.

It is your responsibility to confirm that the health insurance charge is removed from your bill after completing and returning the verification form.  Go to web address:  http://utlink.uth.tmc.edu to view your bill.

"I understand that all students enrolled at The University of Texas Health Science Center at Houston (UTHSC-H) are required to have and maintain health insurance coverage on a continual basis while enrolled at UTHSC-H.  I further understand and agree that failure to have and maintain health insurance coverage may result in the cancellation of my registration.  I understand and agree that I am responsible for any and all charges related to my medical care. 

I hereby certify that I have and will maintain current health insurance coverage while enrolled as a student at UTHSC-H.”
       
Last Name
   
First Name
 
Middle Name
 
E-mail address
For confirmation of receipt of this form
 

Student ID Number

    
School or Program
   
Semester
    
Name of Insurance Co.
Other than student insurance through UTHSC-H		    


International Students
Insurance includes Repatriation and Medical Evacuation
Yes
No
If any questions, please contact Auxiliary Enterprises at 713 500 8400 for further information.


   

Date

    
     
     

Submit this form electronically by hitting the submit button below.

If you have any questions, please send an email to student-insurance@uth.tmc.edu