Boston University Boston University

 

Boston University

 

 

NOTE: (The student may list any additional health insurance policies that cover the student on the reverse side of this firm)
READ SECTION BELOW CAREFULLY. IF YOUR ALTERNATE HEALTH INSURANCE PLAN MEETS THESE CONDITIONS,
YOU MAY SIGN AND SUBMIT THIS FORM:


• I certify that my health insurance plan that I have listed on this waiver form is now in force and will be maintained for the full
2011/2012 academic year.


• I certify that my health insurance plan which I have listed on this waiver form will provide me throughout the school year with
reasonably comprehensive coverage of health services, including preventive and primary care, emergency services, surgical
services, hospitalization benefits, ambulatory patient services, and mental health services.


• I certify that these services provided by my health insurance plan are reasonably accessible to me in the area where I am attending school. I understand that a health insurance plan that covers only emergency services where I am studying is not
comparable coverage and does NOT qualify for a waiver.


• I understand that payment from the Massachusetts Health Safety Net (Free Care) does NOT qualify for a waiver.


• I understand that coverage under Commonwealth Care does NOT qualify for a waiver.


• I certify that I have compared my health insurance plan to the Boston University Student Medical Insurance Plan and I have
determined the benefits to be at least comparable.


• I understand that I will be responsible for all medical insurance expenses incurred by myself/son/daughter and neither Boston
University nor its student medical insurance plan will be responsible.


• I attest that no claims have been submitted for payment under the Boston University student medical insurance plan for the

2011//2012 policy year.


For students studying in the United States:
• I certify that the health insurance company that I have listed on this waiver form is a U.S. (domestic) insurance carrier. I
understand that coverage through a foreign insurance carrier or through a foreign national health service program is NOT
acceptable for waiver purposes.
For students studying outside the United States (if the plan listed above is not from a domestic insurance carrier):


• I certify that if I visit the United States during the 2011/2012 policy year, I will purchase a qualifying domestic health insurance
plan for the period of my stay in the United States and I will report the details of that plan to Boston University Student Accounting
Services, before or upon my arrival in the U.S.


• All students (and parents/guardians) signing the waiver form: I certify the above information is true and accurate.

 

 

 

Student Rates Annual
8/23/11 - 8/22/12
Spring
1/1/12 - 8/22/12
Basic Plan Premium:
Deductible:
$1,914
Non-Preferred Care: $250
$1,260
Non-Preferred Care: $250
Plus Plan Premium:
Deductible:
$2,647
Non-Preferred Care: $250
$1,729
Non-Preferred Care: $250

Dependent Rates
(Basic Plan ONLY)
Annual
8/23/11 - 8/22/12
Spring
1/1/12 - 8/22/12
Spouse Only Premium:
Deductible:
$4,140
Non-Preferred Care: $250
$2,654
Non-Preferred Care: $250
Child(ren) Premium:
Deductible:
$2,264
Non-Preferred Care: $250
$1,452
Non-Preferred Care: $250

 

 

 

 

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https://www.aetnastudenthealth.com/stu_conn/student_connection.aspx?groupid=711110

 

 

 

insurance waiver form

 

http://www.bu.edu/studentaccountingservices/files/2010/07/Medical-Insurance-Waiver-Form.pdf

 

 

 

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Beth Israel Deaconess Medical Center
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Laboratory, Neonatal and Perinatal Medicine, Obstetrics, Outpatient Facility, Pediatric Psychiatry, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Surgery - Cardiovascular, Surgery - Transplant, Surgery Center
Estimated Distance: 0.5 miles
330 Brookline Ave
Boston, MA 02215-5400
617-667-7000

 
Childrens Hospital
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - Pediatric, Laboratory, Neonatal and Perinatal Medicine, Occupational Medicine, Pediatric Psychiatry, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Surgery Center
Estimated Distance: 0.6 miles
300 Longwood Ave
Boston, MA 02115-5724
617-355-6000
 
Dana-Farber Cancer Institute
Specialties: Ambulatory Surgical Center, Emergency Medicine, Hospital - General, Hospital - Pediatric, Occupational Medicine, Occupational Therapy, Outpatient Facility, Physical Therapy, Rehabilitation, Occupational & Physical Therapy, Surgery - Transplant, Surgery Center
Estimated Distance: 0.7 miles
450 Brookline Ave
Boston, MA 02215-5418
617-632-3000
 
Brigham and Womens Hospital
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Pediatric, Hospital - Psychiatric, Laboratory, Neonatal and Perinatal Medicine, Obstetrics, Occupational Medicine, Occupational Therapy, Outpatient Facility, Pediatric Psychiatry, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 0.8 miles
75 Francis St
Boston, MA 02115-6110
617-732-5500
 
Arbour Hri Hospital
Specialties: Hospital - Psychiatric, Substance Abuse
Estimated Distance: 1.1 miles
227 Babcock St
Brookline, MA 02446-6773
617-731-3200
 
Arbour Hri Hospital
Specialties: Hospital - Psychiatric, Substance Abuse
Estimated Distance: 1.1 miles
227 Babcock St
Brookline, MA 02446-6773
617-731-3200
 
Arbour Hri Hospital
Specialties: Hospital - Psychiatric, Substance Abuse
Estimated Distance: 1.1 miles
227 Babcock St
Brookline, MA 02446-6773
617-731-3200
 
Arbour Hri Hospital
Specialties: Hospital - Psychiatric, Substance Abuse
Estimated Distance: 1.1 miles
227 Babcock St
Brookline, MA 02446-6773
617-731-3200
 
New England Baptist Hospital
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Laboratory, Occupational Medicine, Occupational Therapy, Outpatient Facility, Physical Therapy, Radiology, Rehabilitation, Occupational & Physical Therapy, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 1.2 miles
125 Parker Hill Ave
Roxbury Crossing, MA 02120-2847
617-754-5800
 
Boston Medical Center
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Laboratory, Obstetrics, Occupational Medicine, Outpatient Facility, Pediatric Psychiatry, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 1.5 miles
1 Boston Medical Ctr Pl
Boston, MA 02118-2908
617-414-5000
 
Massachusetts Eye and Ear Infirm
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Pediatric, Hospital - Psychiatric, Laboratory, Occupational Medicine, Occupational Therapy, Outpatient Facility, Pediatric Psychiatry, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 1.9 miles
243 Charles St
Boston, MA 02114-3002
617-523-7900
 
Massachusetts General Hospital
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Pediatric, Hospital - Psychiatric, Laboratory, Neonatal and Perinatal Medicine, Obstetrics, Occupational Medicine, Occupational Therapy, Outpatient Facility, Pediatric Psychiatry, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 1.9 miles
55 Fruit St
Boston, MA 02114-2621
617-726-2000
 
New England Sinai Hospital and Rehabilitation Center at New England Medical Center
Specialties: Hospital - Rehabilitation, Occupational Therapy, Physical Therapy, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 1.9 miles
750 Washington St
Boston, MA 02111-1526
617-636-1069
 
Tufts Medical Center
Specialty: Hospital - General
Estimated Distance: 1.9 miles
800 Washington St
Boston, MA 02111-1552
617-636-5000
 
Cambridge Health Alliance
Specialty: Hospital - General
Estimated Distance: 2 miles
1493 Cambridge St
Cambridge, MA 02139-1047
617-665-2300
 
Arbour Hospital
Specialty: Hospital - Psychiatric
Estimated Distance: 2.2 miles
49 Robinwood Ave
Boston, MA 02130-2156
617-522-4400
 
Arbour Hospital
Specialty: Hospital - Psychiatric
Estimated Distance: 2.2 miles
49 Robinwood Ave
Boston, MA 02130-2156
617-522-4400
 
Arbour Hospital
Specialty: Hospital - Psychiatric
Estimated Distance: 2.2 miles
49 Robinwood Ave
Boston, MA 02130-2156
617-522-4400
 
Arbour Hospital
Specialty: Hospital - Psychiatric
Estimated Distance: 2.2 miles
49 Robinwood Ave
Boston, MA 02130-2156
617-522-4400
 
Arbour Hospital
Specialties: Hospital - Mental Health, Hospital - Psychiatric
Estimated Distance: 2.2 miles
49 Robinwood Ave
Boston, MA 02130-2156
617-522-4400

 

 

Spaulding Rehabilitation Hospital Boston
Specialties: Hospital - Pediatric, Hospital - Psychiatric, Hospital - Rehabilitation, Pediatric Psychiatry, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy, Substance Abuse
Estimated Distance: 2.3 miles
125 Nashua St
Boston, MA 02114-1101
617-720-6400

 
Spaulding Rehabilitation Hospital Boston
Specialties: Hospital - Pediatric, Hospital - Psychiatric, Hospital - Rehabilitation, Pediatric Psychiatry, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy, Substance Abuse
Estimated Distance: 2.3 miles
125 Nashua St
Boston, MA 02114-1101
617-720-6400
 
Steward St Elizabeths Medical Center of Boston
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Laboratory, Neonatal and Perinatal Medicine, Obstetrics, Outpatient Facility, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 2.5 miles
736 Cambridge St
Brighton, MA 02135-2907
617-789-3000
 
Mount Auburn Hospital
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Laboratory, Neonatal and Perinatal Medicine, Obstetrics, Occupational Medicine, Occupational Therapy, Outpatient Facility, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 2.6 miles
330 Mount Auburn St
Cambridge, MA 02138-5502
617-492-3500
 
Somerville Hospital
Specialties: Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Laboratory, Outpatient Facility, Pediatric Psychiatry, Physical Therapy
Estimated Distance: 3.1 miles
230 Highland Ave
Somerville, MA 02143-1408
617-666-4400
 
Faulkner Hospital
Specialties: Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Laboratory, Occupational Medicine, Occupational Therapy, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 3.4 miles
1153 Centre St
Boston, MA 02130-3446
617-983-7000
 
Bournewood Hospital
Specialties: Hospital - Chemical Dependency, Hospital - Mental Health, Hospital - Psychiatric, Psychiatry, Substance Abuse
Estimated Distance: 4.2 miles
300 South St
Brookline, MA 02467-3658
617-469-0300
 
Whidden Memorial Hospital
Specialty: Hospital - General
Estimated Distance: 5.4 miles
103 Garland St
Everett, MA 02149-5066
617-389-6270
 
Lawrence Memorial Hospital of Medford
Specialties: Ambulatory Surgical Center, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Pediatric, Hospital - Psychiatric, Rehabilitation, Occupational & Physical Therapy, Substance Abuse
Estimated Distance: 5.5 miles
170 Governors Ave
Medford, MA 02155-1643
781-306-6000
 
McLean Hospital
Specialties: Hospital - Chemical Dependency, Hospital - Psychiatric
Estimated Distance: 5.9 miles
115 Mill St
Belmont, MA 02478-1064
617-855-2000
 
Beth Israel Deaconess Hospital-Milton
Specialties: Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Occupational Therapy, Outpatient Facility, Physical Therapy
Estimated Distance: 6.6 miles
199 Reedsdale Rd
Milton, MA 02186-3926
617-696-4600
 
Newton-Wellesley Hospital
Specialty: Hospital - General
Estimated Distance: 7.5 miles
2014 Washington St
Newton Lower Falls, MA 02462-1607
617-243-6000
 
New England Sinai Hospital and Rehabilitation Center at Deaconess Waltham
Specialties: Hospital - Rehabilitation, Occupational Therapy, Physical Therapy, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 7.8 miles
20 Hope Ave
Waltham, MA 02453-2721
781-647-6491
 
Quincy Medical Center
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Pediatric, Hospital - Psychiatric, Obstetrics, Outpatient Facility, Physical Therapy, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery Center
Estimated Distance: 7.9 miles
114 Whitwell St
Quincy, MA 02169-1870
617-376-5743
 
Melrose-Wakefield Hospital
Specialties: Ambulatory Surgical Center, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Pediatric, Hospital - Psychiatric, Obstetrics, Rehabilitation, Occupational & Physical Therapy, Substance Abuse
Estimated Distance: 8.1 miles
585 Lebanon St
Melrose, MA 02176-3225
781-979-3000
 
Winchester Hospital
Specialty: Hospital - General
Estimated Distance: 8.3 miles
41 Highland Ave
Winchester, MA 01890-1446
781-729-9000
 
Deaconess-Glover Hospital
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Laboratory, Occupational Medicine, Occupational Therapy, Outpatient Facility, Pediatric Psychiatry, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 8.5 miles
148 Chestnut St
Needham, MA 02492-2505
781-453-3000
 
Deaconess-Glover Hospital
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Psychiatric, Laboratory, Occupational Medicine, Occupational Therapy, Outpatient Facility, Pediatric Psychiatry, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Substance Abuse, Surgery - Cardiovascular, Surgery Center
Estimated Distance: 8.5 miles
148 Chestnut St
Needham, MA 02492-2505
781-453-3000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000

 

 

Healthsouth New England Rehabilitation
Specialties: Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000

 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Healthsouth New England Rehabilitation
Specialties: Hospital - Psychiatric, Hospital - Rehabilitation, Outpatient Facility, Physical Therapy, Psychiatry, Rehabilitation, Occupational & Physical Therapy
Estimated Distance: 8.6 miles
2 Rehabilitation Way
Woburn, MA 01801-6003
781-935-5000
 
Bournewood Caulfield Center
Specialties: Hospital - Chemical Dependency, Hospital - Psychiatric, Substance Abuse
Estimated Distance: 9.4 miles
23 Warren Ave
Woburn, MA 01801-4979
781-932-0649
 
Healthsouth Braintree Rehabilitation
Specialties: Critical Care Medicine, Hospital - Rehabilitation, Occupational Medicine, Outpatient Facility, Physical Therapy, Rehabilitation, Occupational & Physical Therapy, Surgery Center
Estimated Distance: 11 miles
250 Pond St
Braintree, MA 02184-5351
781-848-5353
 
Lahey Clinic Hospital
Specialties: Ambulatory Surgical Center, Cardiac Rehabilitation, Critical Care Medicine, Emergency Medicine, Hospital - General, Hospital - Pediatric, Laboratory, Occupational Medicine, Outpatient Facility, Physical Therapy, Psychiatry, Radiology, Rehabilitation, Occupational & Physical Therapy, Surgery - Cardiovascular, Surgery - Transplant, Surgery Center
Estimated Distance: 11.1 miles
41 Mall Rd
Burlington, MA 01805-0001
781-744-5100
 
Bay Ridge Hospital
Specialties: Hospital - Chemical Dependency, Hospital - Psychiatric, Psychiatry, Substance Abuse
Estimated Distance: 11.4 miles
60 Granite St
Lynn, MA 01904-2915
781-599-9200
 
Westwood Lodge Hospital
Specialties: Hospital - Psychiatric, Mental Health Services, Pediatric Psychiatry, Psychiatry, Substance Abuse
Estimated Distance: 11.4 miles
45 Clapboardtree St
Westwood, MA 02090-2903
781-762-7764

 

 

 

 

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