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HEALTH INSURANCE FEE WAIVER

INTERNATIONAL GA/GRA/GTAS

UTK Student Health Center

1800 Volunteer Blvd

Knoxville, TN 37916

Email waiver to: gradinsurancewaiver@utk.edu

(do not send regular correspondence to this email)

I UNDERSTAND (PLEASE READ AND INITIAL EACH):

____The cost of the insurance is paid by my department ONLY for the months I am an active GA/GRA/GTA

____I must maintain the minimal 25% GA/GRA/GTA appointment to qualify for an insurance fee waiver

____If I lose my assistantship during the academic year, charges for insurance will be added to my Bursar account

____I will be enrolled as an international student and charged for insurance BEFORE I am confirmed in payroll

____I will be enrolled as a GA/GRA/GTA and the insurance fee will be removed AFTER I am confirmed in payroll

____The insurance charge will not be removed from student account until AFTER tuition waiver is processed

____The insurance charge MIGHT NOT BE REMOVED from my account before August 31 (Fall) or January 31 (Spring)

____I must remain insured while actively enrolled as a student at UT Knoxville

____I must advise the Student Health Center of my graduation date

____I will not be automatically enrolled in the insurance plan after I graduate, but I may choose to be insured

____If I enter OPT/CPT, I need to contact the Student Health Center since I may be required to complete a waiver

____If my VISA/CITIZENSHIP status changes, I must contact the Student Health Center immediately

____If am treated at the UT Medical Center, I will be billed for services (copays, deductible, and coinsurance apply)

____The per semester UT Programs & Services Fees (SPSF Part A/B)* and how it is assessed

*This fee MUST be paid to access the on-campus UT SHC AND to qualify for “student pricing” at the UT Medical Center ER

*GRADUATING? OPT/CPT? VISA/CITIZENSHIP CHANGE?

It is imperative that you contact the Student Health Center as soon as this information become available

 If you lose your assistantship at any time during the academic, you will be automatically enrolled with an international status

and charges will be added to your student account for the months you are not employed

I agree to pay charges for insurance if they are added to MyUTK account______(initial here)

______________________________________________________________________________ ___________________

(STUDENT SIGNATURE) (DATE)

STREET ADDRESS: ________________________________________________ APTARTMENT #:_________

CITY: _______________________________________________________________ STATE: _____ ZIP:__________

DATE OF BIRTH (MM/DD/YYYY): ____________________ PHONE NUMBER: (______)_______________________

*Please be sure to update this information in the payroll system

------------------- DO NOT WRITE BELOW - STUDENT HEALTH SERVICE USE ONLY --------------

FEE REMOVED FOR FALL: AUG SEP OCT NOV DEC

SPRING: JAN FEB MAR APR MAY JUN JUL

NOTES:______________________________________________________________________________

AMOUNT REMOVED:_______ AMOUNT CHARGED:_______ WAIVER ENTERED BY:______ DATE:________

PLEASE PRINT LEGIBLY

LAST NAME: ______________________________

FIRST NAME: _____________________________

VISA (CIRCLE ONE): F1 F2 J1 J2 OTHER:_____

STUDENT ID #: 000______________________

DATE OF BIRTH (mm/dd/yyyy): _____________

UT EMAIL: ___________________ @vols.utk.edu

DEPARTMENT: _________________________

SEMESTER: FALL / SPRING YEAR: ___________

(CIRCLE ONE)

EXPECTED GRADUATION DATE: ____________

EFF

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