Student Health and Wellness

Group ID: 635957
Certificate ID: Student ID
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Student Health and Wellness! mystudentplan provides health, prescriptions, dental, mental health care plus additional benefits for eligible students.

Extended Healthcare Benefits & Dental Plan Re-Enroll Application

Only submit this form if you have previously opted out of the health and dental plan and wish to re-enroll. All new eligible students taking 2 courses in eligible programs are automatically enrolled in the benefit plan.

Eligibility Criteria

There are 2 circumstances for re-enrolling in the Student Health and Dental Plan:

1 Program Start Date

Eligible students who previously opted out of the benefits and are attending the school on the anniversary of starting their program and meet the eligibility criteria to be enrolled in the student plan may apply to re-enroll in the plan by the applicable term deadline.

Example: If your program started in January, you only may re-enroll in the plan in January as your anniversary of starting is every winter term.

Fall deadlines to submit applications
Students starting August 1^st, August 20^th, 2024
Students starting September 1^st, September 25^th, 2024

2 Loss of Comparable Coverage

Eligible students who previously opted out of the benefits and have lost their comparable insurance coverage may re-enroll within 30 days of losing that coverage.

Proof of losing coverage must be sent to
tyndaleplan@mystudentplan.ca
after completing this form.

Documentation includes a letter from the insurance carrier or the employer stating the student's name, loss of coverage date, the insurance carrier's name & policy number.

The deadline is within 30 days of losing coverage.

If you do not meet the eligibility criteria to be automatically enrolled in the student plan, please do not complete this form. There is no opt-in to the student plan.

Important notes:

All eligible students are automatically enrolled in the Student Extended Healthcare Benefits & Dental Plan and do not need to submit a re-enroll form. You will see a health insurance fee and dental insurance fee on your student account to confirm you are enrolled.
The effective date of your coverage is the 1st day of the month when your program begins.
There is a 45-day validation period from the start of the term. During this time, you would have to pay out of pocket for all eligible Health and Dental expenses and keep the receipts. After the enrollment process is complete, you will be able to submit online claims for reimbursement and your Plan Card will be automatically activated for pharmacies and dental offices.
NO EXCEPTIONS will be made if the deadline is missed.
Once you complete the Re-enroll form, you will receive an automated email confirmation. Please keep this email for your records as it is your only proof of submitting a Re-enroll request.

Steps to Submitting a Re-Enroll Application:

1Student Information

Complete this section below providing true and correct information. Click NEXT.

2Enrollment Circumstances

Scroll down and check Health Plan/Dental Plan/Qualify. You can choose Health or Dental or both plans. Select your status and Click NEXT.

3Read and Agree to the Terms and Conditions

Click on the checkbox to indicate that you agree to the Terms and Conditions agreement. Click SUBMIT to finish your application.

4Confirmation Email

Check your email and verify if you have received the confirmation email. If you do not receive this email, you must resubmit the form.

5Application Status

You will receive an email with the status of your application.

6Pay the Fees

If your application is approved, the fees will be included in the student account.

Add donotreply@gallivan.ca to your address book. Please do not reply to this email.

Questions? Please contact your Benefit Plan Office: tyndaleplan@mystudentplan.ca

Extended Healthcare Benefits & Dental Plan Re-Enroll Form

Please complete all information on the re-enroll form and we will process your application as soon as we can.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Sex

F

M

U

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Extended Healthcare Benefits & Dental Plan Re-Enroll Application

Eligibility Criteria

Steps to Submitting a Re-Enroll Application:

Extended Healthcare Benefits & Dental Plan Re-Enroll Form

Extended Healthcare Benefits & Dental Plan Re-Enroll Form

Student Information

Benefits Plan Office

General Inquiries Line

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