Clinical Reinstatement of Medical Insurance Coverage


Student Information

Please Choose one of the effective terms:

You cannot Continue or Submit this form for processing until you have checked the Agreement Checkbox.

Yes, By checking the Agreement checkbox, I am hereby requesting to cancel my previous health insurance waiver submitted and reinstate medical insurance coverage as provided by AUC.I understand that this request does not guarantee payment on any medical claims, which I have, or will, submit to the carrier. I further understand that I will be billed by AUC and responsible for the appropriate insurance premium payment. Failure to remit the premium payment may result in the cancellation of my coverage. In addition, I also acknowledge that my checking the Agreement Box, it represents my Electronic Signature.

Please Note: Requests to reinstate coverage will be processed and coverage will be reinstated within 7 - 10 Business Days.

For questions regarding claims and coverage, contact Aetna at (877) 381-3551 or .