Student Health Insurance Forms
If you have any questions about a form or do not see the form you need,
please contact the Office of Student Health Insurance at 303-837-2127 or
email studenthealthinsurance@cuanschutz.edu.
Anschutz Health & Wellness Center Massage Therapy Reimbursement Form
Form to be used to request reimbursement for massage therapy services rendered at the Anschutz Medical Campus Health & Wellness Center
Generic Massage Therapy Reimbursement Form
Form to be used to request reimbursement for massage therapy services rendered at the facility of your choice.
Claim Information Form
Standard form to provide notice of claim and/or provide details on requests for additional information.
Personal Representative Appointment Form
This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare StudentResources.
Prescription Reimbursement Form
Optum Rx claim form to request reimbursement for covered medications purchased at retail cost.
PRI-SI-FO-09 Authorization From Individual
This form allows an insured to provide specific instructions to UnitedHealthcare StudentResources for use or disclosure of protected health information for a particular purpose.
Continuation Coverage Enrollment
Graduates can opt in for 1-3 months of continuation coverage through the CU Anschutz Student Insurance Plan. This enrollment opportunity can be accessed via your UHCSR MyAccount. When you log in, you will go to the "action center" tab at the top and you will see an option to "enroll into continuation coverage." When you select the option to "take action" you will see the option to select 1, 2, or 3 months of coverage. Once you have selected which option you prefer, you can proceed with payment. Additionally, you can enroll for one month at a time if you wish to do so. You would simply select the 1-month option and then if you decide that you want/need to enroll for an additional month, you will just complete the above process again for the following month (for up to 3 months post-graduation coverage end date).
This enrollment request and payment must be received by UHCSR within 15 days of the previous policy end date. For example, for coverage ending 07/31/2021, UHCSR would need the enrollment request and payment by 08/14/2021 in order for a graduate to opt-in for the Continuation Coverage.
Please note: This is only an option for students who were enrolled in the CU Anschutz Student Health Insurance Plan for the semester in which they graduated.