Opt Out Request Form

For UBC International Students already covered by Canadian Provinical Coverage only
Please note: This is not the correct optout form for ELI Students

* = required field

Personal Information

* First Name:

* Last Name:

Student Number:

* Date of Birth:

(mm/dd/yyyy)

* Effective date shown
on IMED Card:

Year:

* Telephone #:

* Email address:

* Program type:

* Indicate why you are requesting to opt out

	I am already covered on Health Insurance BC (MSP)
	Indicate the date your MSP coverage began	(mm/dd/yyyy)

	I am already covered on the provincial / territorial health plan of
	Effective Date	(mm/dd/yyyy)

For either of the two reasons above, the following supporting documentation is required: a copy of your MSP billing statement letter confirming your coverage on your provincial / territorial plan or proof of payment to MSP (MSP card alone is NOT an accepted proof of coverage)*


(You are allowed to upload these type of files: jpg, gif, png, bmp, tiff, doc, docx and pdf. We recommend jpg format and maximum file size of 1.5 mb.)

	I purchased three months of Advance iMED Coverage directly through DCIS.

	This reason only applies to degree and two-term exchange students. Please attach a copy of your study permit with this form:


	(file type requirement same as above)

See the “Opting Out” page of the “Enrolment” section at the iMED Website (www.david-cummings.com/imed) to view submission deadlines for opting out.

If your opt out request is approved, the iMED fee will be credited to your tuition account.