Request to opt-out of the University Student Health Plan due to enrollment in a Maryland Health Connection ACA health plan on or prior to February 1, 2014

I certify that I have enrolled in a MHC health plan on or prior to February 1, 2014 but have not received my enrollment card or other proof of insurance and request a waiver to opt-out of the University Student Health Plan for the Spring 2014 semester.

I further agree that I will complete the standard university waiver form and submit it to the Student Health Center within 10 days after I have received an enrollment card or other proof of coverage.