Enrollment/Opting-In Form

  • Check out the Important Dates for enrollment periods and policy dates.
  • Enrollment/Opting-In can be completed on the UHCSR website.
  • The Enrollment Form must be filled out during the Enrollment/Waiver period, prior to adding dependents or printing off your ID Card.  
  • If the enrollment form isn't online, that means the Enrollment Period has ended.
  • If you need to receive medical services prior to the end of the Enrollment Period, please complete and submit this form.  Otherwise, you will be auto-enrolled with 3 business days following the end of the Enrollment Period.