Dartmouth College Health Service
5-7 Rope Ferry Road, HB 6143
Hanover, NH 03755
DSGHP Waiver Requirements
Plan Year: 2014 - 2015
Dartmouth College requires all students who are listed as active in the student information system (Banner), including students not taking classes or on a leave term, to have health insurance meeting specified standards of coverage. To insure this happens, all active Dartmouth students are automatically enrolled in the DSGHP each September 1st, and the related fee is billed to their student tuition account in August. To waive enrollment in the DSGHP students must submit a new, completed waiver petition each academic year by July 1 to avoid late fees.
2014 - 2015 DSGHP Waiver Conditions
All nine (9) conditions must be answered at the start of each academic year for DSGHP enrollment to be waived.
- My coverage is provided by a company licensed to do business in the United States and has a U.S. claims office and telephone number. (Foreign state government plans do NOT meet this requirement.)
- My plan provides coverage for inpatient and outpatient mental health care and chemical/substance abuse treatment and the benefits include at least twenty (20) outpatient mental health and/or biologically based illness visits in the Hanover, NH area.
- The maximum benefit for my coverage is $500,000 or more per year.
- If my plan has in‐network and/or out‐of‐network co-payments, co-insurance and deductibles, I understand that I am responsible for those
- My plan includes non‐emergent medical and prescription coverage in the Hanover, NH area.
- My plan will remain effective or be renewable for the plan year beginning September 1, 2014 and ending August 31, 2015. If my coverage changes during this time, I understand that I must apply for another waiver. I also understand that failure to file a new waiver, if my plan changes, may result in automatic enrollment and an associated charge to my tuition account.
- I certify that all of the answers provided above are true and accurate. I further understand by submitting this form, I am granting permission for Dartmouth to submit this form through a waiver verification process. If it is determined that my plan does not provide comparable coverage or the information is falsified, I understand I will be enrolled in the DSGHP and my student account will be charged the full insurance premium.
- I understand that in order for this waiver to be processed, I need to send a front and back copy of my medical and prescription insurance ID card(s) to the DSGHP Office.
- I understand that if I am submitting this waiver after the July 1, 2014 deadline, late fees will be applied.
Click Here to be brought to the Dartmouth Student Group Health Plan home page.