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)