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)