Health Insurance Waiver for Commuting Canadians

As a commuting Canadian, you have presented documentation that verifies you are covered under the Ontario Health Insurance Program. However, the Ontario Ministry of Health states, "if you have a valid Ontario Health card, you are entitled to certain benefits when outside of Canada. But, because coverage for out-of-country health care services is limited, it is recommended you purchase the current WSU international student insurance through CHP."

By completing the form below I confirm that I am currently a Commuting Canadian studying at Wayne State University. I am covered under the Ontario Health Insurance Plan provided by the Ontario Ministry of Health. I understand that many health services outside of Canada cost much more than the ministry pays and that I am liable for any difference in cost should I have to access any health care services while in the United States. I also understand that the ministry does not cover some health services and should an emergency occur I will have to pay the full costs for them.


First Name:
Last Name:
Date of Birth:
Gender
Student ID (9 digits):
SEVIS ID (12 digits):
Immigration Status:
Address:
Phone Number:
Email Address:
OHIP Card (Attachment #1):
OHIP Card (Attachment #2):
Attach a copy of the front and back of your OHIP Card.
  
Being fully aware of the limitations of my OHIP coverage while in the United States, I request to waive out of purchasing the Wayne State University health insurance plan.