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Student Insurance Forms

Anschutz Medical Campus Student Health

Insurance Forms for the 2019-2020 plan year

​​Standard form to provide notice of claim and/or provide details on requests for additional information. 

Form to be used to request reimbursement for massage therapy services rendered at the Anschutz Medical Campus Health & Wellness Center

Form to be used to request reimbursement for massage therapy services rendered at the facility of your choice

This document allows an insured to appoint a personal representative to act on their behalf in the matters of health insurance with UnitedHealthcare StudentResources.

Optum Rx claim form to request reimbursement for covered medications purchased at retail cost. 

This form allows an insured to provide specific instructions to UnitedHealthcare StudentResources for use or disclosure of protected health information for a particular purpose.

Graduates can opt in for 1-3 months of continuation coverage through the CU Anschutz Student Insurance Plan.  This form along with the premium payment can be mailed to UnitedHealthcare StudentResources to request continuation coverage (similar to COBRA).

If you have any questions about a form or do not see the form you need, please contact the Office of Student Health Insurance at 303-837-2127 or email

Office of Student Health

Phone: 303-724-7674

Street Address: Education II, North, Room #3213


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