DSGHP Forms

2022 - 2023 DSGHP Forms

• 22 - 23 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. 
• 22 - 23 Midyear Cancellation
  • To cancel the DSGHP coverage for a student or dependent(s) onone of the two midyear cancellation dates.
• 22 - 23 Dependent Application
  • To enroll qualifying dependents.
• 22 - 23 Waiver Rescindment
  • To rescind an approved waiver.

• Medical Claim Form
  • For medical/mental health claims
• Prescription Claim Form
  • For prescription claims.
• COVID-19 OTC Test Reimbursement Form
  • For COVID-19 over the counter (take home) tests purchased after January 15, 2022.
• 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)