Fall 2006
064
CampusCare Disenrollment Form
Name
Student ID# Date

Coverage Period: August 14, 2006 through December 31, 2006
I wish to have the CampusCare Health option cancelled effective/retroactive to August 14, 2006 and to have the $80.00 charge removed from my University of Arizona student account.  I understand that any cost for services rendered as of August 14, 2006 will be my responsibility and that if I wish to continue CampusCare in the future, I will need to reenroll during an open enrollment period.

Signature

This form must be received by September 5, 2006 as this is the last day to drop coverage

Mail, fax or bring to:

Campus Health Service(Insurance Office)
University of Arizona
P.O. Box 210095
Tucson AZ 85721-0095

For more information call us at:

  • Phone:(520) 621-5002
  • Fax:(520) 626-8616