Health Forms

Health Insurance Coverage and Waiver Form

Massachusetts law requires all enrolled students to participate in a qualifying student health plan.

If you have other comparable health insurance coverage and want to remove the $1,679 health insurance charge from your student bill, you must submit online† a completed waiver form (available beginning May 31) by the July 20 deadline for the 2017-2018 policy year.

Students enrolling in fall 2017 who do not complete a health insurance waiver/enrollment form by the deadline above will be automatically enrolled in, and charged for, the Clark University Student Health Insurance Plan so the University will be in compliance with Massachusetts law.

†International students: please view separate procedure and information

On this page you will find information about required health forms, health insurance waivers and special information for student-athletes and international students.

Forms Required of All Students

Please download, complete and return the required health forms listed below by July 1, 2017.

Mail your completed forms to:

Director of Health Services
Clark University
950 Main Street
Worcester MA 01610-1477

Please keep a copy of all of your forms for your records. You will be notified via your Clark email about the status of your health forms. You are responsible for checking your Clark email regarding your forms compliance. Please do not call Health Services if you have not returned your forms by the deadline.

*Students should get any needed immunizations with medical practitioners in their home country or state to avoid charges for immunizations and registration holds after arriving at Clark.

**Health Services will accept physical examinations completed within the past two years.

Additional Required Health Forms for Athletes

Club Sports

If you plan to participate in club sports, please download and bring your preparticipation physical evaluation form, below, to your medical appointment.

Club Sports Preparticipation Physical Evaluation [PDF]

The completed club sports form should be mailed to:

Director of Health Services
Clark University
950 Main Street
Worcester MA 01610

Varsity Athletics

If you plan to participate in varsity athletics, please download and bring the athletics physical exam form below to your medical appointment. The athletics physical examination must be performed within six months of the start of your initial athletic season, stating clearance for sports activity, and must be signed by a doctor, nurse practitioner or physician assistant.

Varsity Athletics Preparticipation Physical Evaluation [PDF]
ADD-ADHD Form [PDF]

The completed varsity athletics forms should be mailed to:

Clark University Sports Medicine Office
950 Main Street
Worcester MA 01610

Health Insurance Waiver

Complete the health insurance waiver form if you have other comparable health insurance coverage and want to remove the $1,679 health insurance charge from your student bill. See the information below for waiver procedures for domestic and international students.

Fall 2017 incoming students who do not complete a health insurance waiver/enrollment form by the deadline below will be automatically enrolled in, and charged for, the Clark University Student Health Insurance Plan so the University may comply with Massachusetts law.

Waiver Procedure for Domestic Students

All eligible students enrolling for the fall must complete an online waiver form (available May 31) for the 2017-2018 policy year by July 20.

Waiver Procedure for International Students

In order to ensure that international students have access to health care, and to maintain compliance with Massachusetts laws requiring students to participate in a qualifying student health plan, international students may not waive the student health insurance plan using the online registration process, but will instead need to:

  • Complete this written waiver request [PDF]
  • Submit documentation showing their plan's benefits and coverage
  • Provide a copy of a valid health insurance card

Requests for a waiver will be reviewed by the Health Insurance Appeal Committee.

Waivers for international students will be allowed only under limited circumstances:

  • The student has embassy-sponsored health insurance, with benefits comparable to the Clark student health insurance plan.
  • The student has comparable health insurance through his or her spouse's health insurance plan.
  • The student has comparable health insurance provided through a U.S.-based employer.

Please note that coverage by insurance carriers outside of the United States, or coverage by foreign national health service programs, is not acceptable. Please also be aware that international student health insurance plans, made available by firms such as Compass Benefits Group, PSI, etc., do not provide adequate benefits and cannot be used to waive the student health insurance program requirement.

Because health insurance in the United States is often very different from that in many other countries, it can be difficult for international students to understand why their insurance is not adequate and why they need to purchase additional coverage through the student health insurance plan. If you have any questions or concerns about the waiver procedure, please contact the Business Manager.

International Student Health Insurance Waiver Information [PDF]
International Student Health Insurance Waiver Appeal Form [PDF]

Questions?

Visit Clark University Health Services or call 508-793-7467.