Skip to main content Skip to main site menu
Georgetown University.
Georgetown University.
Student Health Insurance
Search Menu
× Close the search box
  • Premier Plan
    • COVID Benefits for 2020-2021 Premier Plan Members
    • Virtual Services
    • Premier Plan Changes
    • FAQs
    • Premier Plan Services
    • Summary Of Benefits & Coverage
    • Deductibles, Copayments, & Coinsurance
    • Premier Plan At A Glance
    • Certificate of Coverage
    • Certificate of Coverage (Last Year)
  • Activate Plan
    • Eligibility
    • Open Enrollment Rates and Dates
    • Early Arrival
    • Calendar Year Continuation
    • J1 or F1 December Graduates
    • MLOA Credit Hour Reduction
    • Late Enrollment & Qualifying Events
    • ID Cards & Coverage Letters
    • Premier Plan Change of Address
    • Acceptance Terms of Agreement
  • Waive Plan
    • Checklist For Other Coverage
    • Waiver Requirement
    • Enrollment Requirement for J1 or F1 Visa Holders
    • Late Waiver Fee Penalty
    • Waiver Terms of Agreement
  • Reduce Costs
    • Prescription Claims
    • Medical & Mental Health Claims
    • Claims Process
    • Premier Plan Forms
  • Voluntary Dental – Apply
    • Student Dental – Benefit Highlights
    • Student Dental - Eligibility, Open Enrollment, Rates & Dates
    • Student Dental - Terms and Conditions
    • Student Dental - ID Cards
  • Other SHI Plans
    • Study Abroad Plan Rates and Dates
    • Study Abroad Plan Resources
    • Study Abroad Vs. the Premier Plan
    • Study Abroad Plan ID Cards
    • Study Abroad Plan Description of Benefits
    • Study Abroad Forms
    • STINT Resources
    • STINT ID Cards
    • STINT Benefit Summary
    • STINT Certificate of Coverage
  • GAGE-AFT Union Members
  • About Us
    • Contact SHI
    • Hoya Wellness Wheel & Resources
    • Medical Care, Student Health Center
    • Counseling & Mental Health
    • Health Education Services
    • Student Outreach & Support
    • Health Issues
    • Navigating The Health System
  • Premier Plan
    • COVID Benefits for 2020-2021 Premier Plan Members
    • Virtual Services
    • Premier Plan Changes
    • FAQs
    • Premier Plan Services
    • Summary Of Benefits & Coverage
    • Deductibles, Copayments, & Coinsurance
    • Premier Plan At A Glance
    • Certificate of Coverage
    • Certificate of Coverage (Last Year)
  • Activate Plan
    • Eligibility
    • Open Enrollment Rates and Dates
    • Early Arrival
    • Calendar Year Continuation
    • J1 or F1 December Graduates
    • MLOA Credit Hour Reduction
    • Late Enrollment & Qualifying Events
    • ID Cards & Coverage Letters
    • Premier Plan Change of Address
    • Acceptance Terms of Agreement
  • Waive Plan
    • Checklist For Other Coverage
    • Waiver Requirement
    • Enrollment Requirement for J1 or F1 Visa Holders
    • Late Waiver Fee Penalty
    • Waiver Terms of Agreement
  • Reduce Costs
    • Prescription Claims
    • Medical & Mental Health Claims
    • Claims Process
    • Premier Plan Forms
  • Voluntary Dental – Apply
    • Student Dental – Benefit Highlights
    • Student Dental – Eligibility, Open Enrollment, Rates & Dates
    • Student Dental – Terms and Conditions
    • Student Dental – ID Cards
  • Other SHI Plans
    • Study Abroad Plan Rates and Dates
    • Study Abroad Plan Resources
    • Study Abroad Vs. the Premier Plan
    • Study Abroad Plan ID Cards
    • Study Abroad Plan Description of Benefits
    • Study Abroad Forms
    • STINT Resources
    • STINT ID Cards
    • STINT Benefit Summary
    • STINT Certificate of Coverage
  • GAGE-AFT Union Members
  • About Us
    • Contact SHI
    • Hoya Wellness Wheel & Resources
    • Medical Care, Student Health Center
    • Counseling & Mental Health
    • Health Education Services
    • Student Outreach & Support
    • Health Issues
    • Navigating The Health System
Skip contextual nav and go to content
Navigate to...    
  • Reduce Costs
    • Prescription Claims
    • Medical & Mental Health Claims
    • Claims Process
    • Premier Plan Forms
Home ▸ Reduce Costs ▸ Premier Plan Forms

Premier Plan Forms

How To Obtain a 1095B Tax Form 
UHCSR Claim Form 
Prescription Claim Form 
HPV Vaccine Medical Claim Form 
Prescription Extension Request Form 
To obtain prescriptions beyond the authorized 30 days when traveling outside of the United States.

 

Georgetown University seal.

Student Health Insurance

1420 36th Street, NW

Washington DC

  • Maps
  • Copyright
  • Privacy
  • Accessibility
  • Full Site Menu