DSGHP Forms

2021 - 2022 DSGHP FORMS

21 - 22 Midyear Enrollment

  • To enroll into the DSGHP after September 1st, due to a loss of other coverage, or during the terms you are enrolled into a study abroad program.

21 - 22 Midyear Cancellation

  • To cancel the DSGHP coverage for student or dependent(s) on one of the two midyear cancellation dates.

21 - 22 Dependent Application

  • To enroll qualifying dependents.

21 - 22 Waiver Rescindment

  • To rescind an approved waiver.

21 - 22 DSGHP Medical Claim Form

  • For medical claims.

21 - 22 DSGHP Prescription Claim Form

  • For prescription claims.

21 - 22 DSGHP Tax Forms & When Coverage Ends Information

  • 1099HC (Massachusetts residents only)
  • 1095-B (All DSGHP enrollees)
  • Extending DSGHP coverage after leaving the college
  • HIPAA letter (Proof of coverage terminating, typically needed for enrollment in other health/insurance plans)