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To view or print the PDF files, you’ll need a free utility called Adobe Reader. If you already have Adobe Reader and still have trouble opening these forms you might need to download the most recent version of Adobe Reader.
Personal Representative Appointment Form (PRA)/Yearly Authorization Form
If you would like a parent or another specific person to assist you with filing your claim(s) and to be able to discuss details of your claim(s) with our claim department, you will need to complete and sign this form. The Yearly Authorization Form gives us permission to discuss any and all medical conditions with your Personal Representative throughout the school year. This form is filled out once and is good for every injury/sickness for the entire school year.
Specific Case Authorization Form
If you would like a parent or another specific person to assist you with filing your claim and to be able to discuss details of your claim with our claim department, you will need to complete and sign this form. The Specific Case Authorization Form gives us permission to discuss only one specific medical condition with your Personal Representative, as you would specify on the form.
Dependent ONLY – Enrollment Form
This is the form that you will use to sign up for the School Injury and Sickness plan. It will show you the rates, coverage periods, and any optional coverages available to you.
This form can help you get reimbursed for all covered medical benefits which you have already paid out of pocket. Please keep in mind when you are requesting reimbursement:
Please download this form if you’ve received a request from us for more information regarding a claim submitted by your doctor or if you would like to speed up the claim process. By providing the injury/sickness information we are able to process your claim accurately and efficiently.
Mail to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025
Or fax to:Â
469-229-5625
This form is used for reimbursement of prescription drugs. If you did not present your ID card when you purchased your prescription out of pocket, you will need to submit this form for a refund. Along with this form for prescriptions filled at a network pharmacy, please attach the paid prescription receipt and the paid cash receipt to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
This form describes how we will obtain your written authorization prior to use or disclosure of your health information. We are required by law and committed to protecting the privacy of your health information. This form explains how we may use information about you and when we can disclose that information to others. You also have rights regarding your health information that are described in this notice.
Travel Assistance – UHCG Program Guide
Anytime you travel more than 100 miles from your home or to another country and experience a medical emergency, you can make a single phone call to the Operations Center for help! You call will be answered by a medically-certified crisis managers who can put in motion a vast number of emergency resources to solve any problem, 24/7.
This program provides discounts on a wide variety of health care services from a nationwide network of health care professionals and facilities. This booklet describes the products and services available to you at discounted rates. There is no additional charge to you for the discount program.
Included with most student health insurance policy is the UnitedHealth Allies discount card. To see if Student Health Allies is included with your plan, please review your brochure or check your permanent ID card.
We’re confident that the UnitedHealth Allies program can help you stretch your health care dollar on:
Dental Care
Save from 10% to 35% on a range of dental services including routine cleaning, x-rays, even cosmetic dentistry, such as teeth whitening.
Vision Care
Pay no more than $40 for an annual eye exam, and save 10% to 20% on eyeglasses from participating eye care professionals and retail vision chains and fittings for contact lenses (not included in annual eye exams).
Wellness products and services
Be healthier and save money with discounts of 10% to 50% on weight management, fitness memberships and equipment, relaxation resources, natural products, and vitamins and supplements.
Prescription drugs
Save at the pharmacy or through the mail. Not available on plans that utilize the UnitedHealthcare Network Pharmacy Program (Medco).
Your UnitedHealth Allies ID card will be delivered along with your student health insurance ID card. Once received, log onto WWW.SR.UNITEDHEALTHALLIES.COM, and register to begin using the program immediately.
UnitedHealth Allies is not insurance. UnitedHealth Allies provides discounts at certain health care providers for medical services. UnitedHealth Allies does not make payments directly to the providers of medical services. The program member is obligated to pay for all health care services, but will receive a discount from those healthcare providers who have contracted with the discount plan organization.
To view or print the PDF files, you’ll need a free utility called Adobe Reader. If you already have Adobe Reader and still have trouble opening these forms you might need to download the most recent version of Adobe Reader.
Personal Representative Appointment Form (PRA)/Yearly Authorization Form
If you would like a parent or another specific person to assist you with filing your claim(s) and to be able to discuss details of your claim(s) with our claim department, you will need to complete and sign this form. The Yearly Authorization Form gives us permission to discuss any and all medical conditions with your Personal Representative throughout the school year. This form is filled out once and is good for every injury/sickness for the entire school year.
Specific Case Authorization Form
If you would like a parent or another specific person to assist you with filing your claim and to be able to discuss details of your claim with our claim department, you will need to complete and sign this form. The Specific Case Authorization Form gives us permission to discuss only one specific medical condition with your Personal Representative, as you would specify on the form.
This is the form that you will use to sign up for the School Injury and Sickness plan. It will show you the rates, coverage periods, and any optional coverages available to you.
This form can help you get reimbursed for all covered medical benefits which you have already paid out of pocket. Please keep in mind when you are requesting reimbursement:
Please download this form if you’ve received a request from us for more information regarding a claim submitted by your doctor or if you would like to speed up the claim process. By providing the injury/sickness information we are able to process your claim accurately and efficiently.
Mail to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025
Or fax to:Â
469-229-5625
This form is used for reimbursement of prescription drugs. If you did not present your ID card when you purchased your prescription out of pocket, you will need to submit this form for a refund. Along with this form for prescriptions filled at a network pharmacy, please attach the paid prescription receipt and the paid cash receipt to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
This form describes how we will obtain your written authorization prior to use or disclosure of your health information. We are required by law and committed to protecting the privacy of your health information. This form explains how we may use information about you and when we can disclose that information to others. You also have rights regarding your health information that are described in this notice.
Travel Assistance – UHCG Program Guide
Anytime you travel more than 100 miles from your home or to another country and experience a medical emergency, you can make a single phone call to the Operations Center for help! You call will be answered by a medically-certified crisis managers who can put in motion a vast number of emergency resources to solve any problem, 24/7.
UnitedHealth Allies Discount Services
This program provides discounts on a wide variety of health care services from a nationwide network of health care professionals and facilities. This booklet describes the products and services available to you at discounted rates. There is no additional charge to you for the discount program.
To view or print the PDF files, you’ll need a free utility called Adobe Reader. If you already have Adobe Reader and still have trouble opening these forms you might need to download the most recent version of Adobe Reader.
Personal Representative Appointment Form (PRA)/Yearly Authorization Form
If you would like a parent or another specific person to assist you with filing your claim(s) and to be able to discuss details of your claim(s) with our claim department, you will need to complete and sign this form. The Yearly Authorization Form gives us permission to discuss any and all medical conditions with your Personal Representative throughout the school year. This form is filled out once and is good for every injury/sickness for the entire school year.
Specific Case Authorization Form
If you would like a parent or another specific person to assist you with filing your claim and to be able to discuss details of your claim with our claim department, you will need to complete and sign this form. The Specific Case Authorization Form gives us permission to discuss only one specific medical condition with your Personal Representative, as you would specify on the form.
Dependent ONLY – Enrollment Form
This is the form that you will use to sign up for the School Injury and Sickness plan. It will show you the rates, coverage periods, and any optional coverages available to you.
This form can help you get reimbursed for all covered medical benefits which you have already paid out of pocket. Please keep in mind when you are requesting reimbursement:
Please download this form if you’ve received a request from us for more information regarding a claim submitted by your doctor or if you would like to speed up the claim process. By providing the injury/sickness information we are able to process your claim accurately and efficiently.
Mail to:
UnitedHealthcare StudentResources
PO Box 809025
Dallas, TX 75380-9025
Or fax to:Â
469-229-5625
This form is used for reimbursement of prescription drugs. If you did not present your ID card when you purchased your prescription out of pocket, you will need to submit this form for a refund. Along with this form for prescriptions filled at a network pharmacy, please attach the paid prescription receipt and the paid cash receipt to:
OptumRx Claims Department
P.O. Box 29044
Hot Springs, AR 71903
This form describes how we will obtain your written authorization prior to use or disclosure of your health information. We are required by law and committed to protecting the privacy of your health information. This form explains how we may use information about you and when we can disclose that information to others. You also have rights regarding your health information that are described in this notice.
Travel Assistance – UHCG Program Guide
Anytime you travel more than 100 miles from your home or to another country and experience a medical emergency, you can make a single phone call to the Operations Center for help! You call will be answered by a medically-certified crisis managers who can put in motion a vast number of emergency resources to solve any problem, 24/7.
UnitedHealth Allies Discount Services
This program provides discounts on a wide variety of health care services from a nationwide network of health care professionals and facilities. This booklet describes the products and services available to you at discounted rates. There is no additional charge to you for the discount program.
Welcome to the Waive Your School’s Insurance Center!
This page is for those students who wish to opt-out (waive) out of the coverage under their school’s student insurance plan. The school’s student insurance plan can only be waived if the student has coverage under another acceptable insurance plan.
The first step to waive out of your school’s student insurance coverage is to verify that you are an eligible student.
2015-2016 Waiver Information
Hard Waiver Student Eligibility
All Students attending Eureka College you are required to purchase this plan unless proof of comparable coverage is furnished. Hard waiver students are required to have health insurance to attend Eureka College
For those students who do not submit an approved waiver form before the deadline, you will be automatically charged and officially enrolled in the Student Health Insurance Plan. Once enrolled there are no refunds or cancellations. (Please note, automatic enrollment will occur AFTER the waiver deadline.)
Please Note:Â If you waive the insurance you will not be eligible to enroll until the following school year unless you experience a Qualifying Life Event.
Hard Waiver Student Waiver Instructions
Waiver Deadlines:
After you verify that you are a hard waiver student and have other insurance you will need:
Once you have completed the waiver form, an email will automatically be sent to the email address you provided notifying you of the waiver request decision. If you receive a:
Please Note:Â If you waive the insurance, you will not be eligible to enroll until the following school year, unless you experience a Qualifying Life Event.
Open Enrollment Periods for all Dependents and Students: If you have eligible dependents in the Fall or are a student in the Fall semester and eligible to purchase coverage and you choose not to enroll for coverage before the Annual Enrollment Deadline of *September 18, 2015, you or your dependents will not be eligible to enroll again until the start of next Fall unless you experience a “Qualifying Life Event†during the year.
*For new dependents or new or renewing students in the Spring semester, your open enrollment deadline is February 26, 2016.
If you did not enroll during your open enrollment period and have since lost coverage under your original plan, you may qualify for a Qualifying Life Event upon providing proof of involuntary loss of coverage and payment within 30 days of losing coverage. (example: marriage, divorce, loss of job, etc) The enrollment form, check or money order, and the letter of creditable coverage must be received within 30 days of losing coverage.After 30 days the student will no longer be eligible to enroll in the plan until Fall of the following school year.
Please CONTACT US for cost and enrollment information as a Qualifying Life Event.
If you have any questions about the waiver process, please call 800-505-4160 or CONTACT US
We are always happy to help in any way.
Included with most student health insurance policy is the UnitedHealth Allies discount card. To see if Student Health Allies is included with your plan, please review your brochure or check your permanent ID card. We’re confident that the UnitedHealth Allies program can help you stretch your health care dollar on:
Dental Care
Save from 10% to 35% on a range of dental services including routine cleaning, x-rays, even cosmetic dentistry, such as teeth whitening.
Vision Care
Pay no more than $40 for an annual eye exam, and save 10% to 20% on eyeglasses from participating eye care professionals and retail vision chains and fittings for contact lenses (not included in annual eye exams).
Wellness products and services
Be healthier and save money with discounts of 10% to 50% on weight management, fitness memberships and equipment, relaxation resources, natural products, and vitamins and supplements. For a complete UnitedHealth Allies brochure on Dental Care, Vision Care, and Wellness Products and Services please click on the link below:
UnitedHealth Allies is not insurance. UnitedHealth Allies provides discounts at certain health care providers for medical services. UnitedHealth Allies does not make payments directly to the providers of medical services. The program member is obligated to pay for all health care services, but will receive a discount from those healthcare providers who have contracted with the discount plan organization.
Welcome to the Student & Dependent Enrollment Center! Here you will find all the necessary tools to enroll in your school sponsored policy.
We suggest you review the brochure for your rates, effective dates and optional coverages before starting the enrollment process. The plan’s benefits can be found in the brochure within the Schedule of Benefits section with the exclusions towards the back.
2015-2016 Enrollment Information
View your school’s BROCHURE
Hard Waiver Student Eligibility
All Students attending Eureka College you are required to purchase this plan unless proof of comparable coverage is furnished.
Begin the enrollment process by following the instructions below.
Hard Waiver Student Enrollment Instructions
Enrollment Deadlines:
Enroll Now
If you have missed the hard waiver enrollment deadline, but have not previously waived out of the insurance, you will be automatically enrolled in the insurance by your school, after the waiver deadline.
If you have previously waived out of the insurance but have since lost coverage due to a Qualifying Life Event please contact us.
Please note: If you do not enroll for the year during the fall open enrollment period, you will not be able to enroll later during the 2015-2016 school year without experiencing a “Qualifying Life Eventâ€. This means that the loss of coverage is no fault of your own or the policyholders (i.e. you get married or become too old to be on a family plan). You will be eligible to enroll within thirty days of this “Qualifying Life Eventâ€. After thirty days, you will no longer be eligible.
Dependent Enrollment Instructions
Eligible students who do enroll may also insure their dependents. Eligible dependents are the student’s spouse and dependent children under 26 years of age. Please see the Enrollment Instructions below.
Deadlines:
Enroll by Mail
To enroll by mail-download an enrollment form and submit by mail using a check or money order. The mailing address is listed on the back of the Enrollment Forms.
The effective date of your dependent’s coverage will be start date of the coverage period you enrolled in
If you did not enroll your dependent during the annual open enrollment period but your dependent has since lost coverage due to a Qualifying Life Event please contact us.
Open Enrollment Periods for all Dependents and Students: If you have eligible dependents in the Fall or are a student in the Fall semester and eligible to purchase coverage and you choose not to enroll for coverage before the Annual Enrollment Deadline of *September 18, 2015, you or your dependents will not be eligible to enroll again until the start of next Fall unless you experience a “Qualifying Life Event†during the year.
*For new dependents or new or renewing students in the Spring semester, your open enrollment deadline is February 26, 2016.
Students who did not enroll themselves or their dependent(s) during the open enrollment period may be able to enroll in the policy if they experience a Qualifying Life Event.
Qualifying Life Events include:
If you and/or your dependents meet the requirements for a Qualifying Life Event, you will need to provide the following:
All documents and payment must be received within 30 days of the qualifying life event. After 30 days, the student or dependents will no longer be eligible to enroll in the plan, until fall of the following school year.
Please Contact Us for cost and enrollment information as a Qualifying Life Event.
If you have any questions about the enrollment process, please call 800-505-4160 or CONTACT US
We are always happy to help in any way.
