Health Insurance Confirmation Coverage Form

Health Insurance Requirement - The recommended minimum health insurance coverage is as follow (the International Students & Scholars Office can recommend U.S. insurance providers if you’re unable to obtain the proper insurance from your home country. You are required to have the minimum following insurance coverage PRIOR to arriving in the U.S. The International Students & Scholars Office will request to see proof of this upon your arrival. The U.S. Embassy may also ask to see proof when you apply for your visa. The minimum level of health insurance is as follows: At least $50,000 for Medical Evacuation to the home country; At least $25,000 for Repatriation of Remains; $100,000 per accident or illness; A deductible not to exceed $500 per accident or illness.

Instructions: As a participation in the program, you are required to obtain health insurance coverage for the duration of your time in the U.S. Students with health insurance through a parent/guardian, or on their own, are responsible for verifying with their health insurance provider if they will have coverage while in the U.S.

Please indicate your current health insurance coverage below and complete the fields below.

Health care provider

Policy Number

Name of Subscriber

Relationship

Expiration date (if any)

Health Care and Special Needs Information

The study abroad experience is one that takes planning and preparation. It is important that health and/or special needs information is provided well in advance. The following information will remain confidential and will not affect your eligibility to participate in the study abroad program.

Are you currently receiving any medical treatment or taking prescribed medications?

Yes, If yes, please name the medication and briefly describe the condition. Note: some medications may not be legal in your study abroad location.

Have you ever or are you currently receiving counseling or psychotherapy, or being treated for any psychological or mental conditions?

Yes, If yes, please state approximate dates and briefly describe the reason

Do you have a documented learning disability?

Yes, If yes, please describe your disability and the accommodations you would need during study abroad. Note: some accommodations may not be available.

Do you have any dietary restrictions based on doctor’s recommendations?

Yes, If yes, please describe.

If there is any additional health information that would be helpful for us to be aware of during your travel, please describe

Communication Approval

It is important that you communicate information to your parents/guardians about the study abroad program details, academics, financial components, as well as your health and wellness arrangements that may need to be made before, during or after your time abroad. There may be circumstances where a representative of UMass Lowell needs to discuss a variety of matters with your parents or guardians. Please read the following statements and check the box regarding what information we can discuss with parents/guardians.

Yes, I authorize the Office of Continuing Education, University officials and/or Faculty Leader(s) to communicate with my parents/guardians/other (referenced below) regarding all issues involving my study abroad experience. This may include, but is not limited to, student account information, student conduct issues, health and safety, or academics. I expressly waive any privacy rights I may otherwise have under FERPA and HIPAA. Such contact may occur before, during or after the program

Emergency Contact Information

Name

Email Address

Relationship to you

Home Phone

Work Phone

Cell Phone

Street Address

City

State

Country

Health Care and Special Needs Information

Communication Approval

Emergency Contact Information

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