F-1 Student Acknowledgement & Insurance Provider Certification Form & Instructions

• All UH Manoa F-1 students need to complete this form to receive your health insurance clearance.
  
  
• Make sure you read the instructions to make sure you have all the appropriate forms and documentation needed in order to prevent any delays in receiving your health insurance clearance.

Form:  F-1 Student Acknowledgement & Insurance Provider Certification Form

IMPORTANT:  If your plan does not meet the minimum levels of coverage required or your insurance company will not complete and sign the F-1 Student Acknowledgement & Insurance Provider Certification Form, then your plan will not be accepted for medical clearance.

F-1 Student Acknowledgement & Insurance Waiver Form

If you are requesting a waiver to the University of Hawaii at Manoa’s health insurance requirement because you will not physically be in the United States, then you need to complete this waiver form to receive your health insurance clearance.

• Make sure you read the instructions to make sure you have all the appropriate forms and documentation needed in order to prevent any delays in receiving your health insurance clearance.

Form:  F-1 Student Acknowledgement & Insurance Waiver Form

For Students on the UH Employer/Employee Health Insurance Plan (through EUTF)

MEMO (for new EUTF member)

If you have applied or will be applying for the EUTF plan (for the first time), have your department complete and sign this memo.

Memo: MEMO (for new EUTF member)

MEMO (for continuing EUTF member)

If you are currently on the EUTF plan and do not have an updated Payroll Notification Form (PNF), then you can have your department complete and sign this memo.

Memo: MEMO (appointment dates)

Last Updated: 08.10.2012