DSGHP Forms

2019 - 2020 DSGHP Forms

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.

Midyear Cancellation

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

Dependent Application

  • To enroll qualifying dependents.

Waiver Rescindment

  • To rescind a waiver.

DSGHP Medical Claim From

  • For medical claims

DSGHP Prescription Claim Form

  • For prescription claims

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)

2020- 2021 DSGHP Forms

2020 - 2021 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.

2020 - 2021 Midyear Cancellation

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

2020 - 2021 Dependent Application

  • To enroll qualifying dependents.

2020 - 2021 Waiver Rescindment

  • To rescind a waiver.

2020 - 2021 Medical Claim Form (Coming Soon)

  • For medical claims

2020 - 2021 Prescription Claim Form (Coming Soon)

  • For prescription claims

2020 - 2021 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)