Booth - Opt-Out Form

Student Health & Wellness!mystudentplan is a benefits plan for students and can provide coverage for prescription drugs, vision care, dental care, mental health counseling, and more. The plan is designed to supplement provincial health insurance and provide additional access to medical services.

Online Forms

Are you covered by a comparable plan? Do you wish to cover your dependents? Or have you opted out of the plan and wish to be re-enrolled? Eligible Students may submit their online forms.

Health and Dental Opt-Out Application

Winter deadline to submit applications
January 26^th, 2024

Eligible students who have comparable Health and Dental coverage and meet the following eligibility criteria may apply to opt out of the benefits before the applicable deadline.

Eligibility Criteria

There are 2 circumstances for opting out of the Student Health and Dental Plan:

1 Fall Academic Enrollment

All students who are eligible for the plan and have comparable Health and Dental coverage from their parents, spouse, government, job, or band may submit an application if they wish to withdraw from the plan before the fall deadline.

If you miss the fall deadline, your next opportunity to opt out would be next fall.

Winter 2024 deadline is January 26^th, 2024

2 Winter Academic Enrollment

Only new eligible students or returning eligible winter students who have NOT attended the fall term, and have comparable heatlh & dental coverage from their parents, spouse, government, job, or band may submit an application if they wish to withdraw from the plan before the winter deadline.

If you miss the winter deadline, your next opportunity to opt out would be next fall.

Winter 2024 deadline is January 26^th, 2024

Things to consider when thinking of opting out:

A parents' insurance plan will stop covering you if you are a part-time student over the age of 21 or a full-time student over the age of 25.
You can coordinate 2 benefit plans and increase your coverage up to 100%! Find out more Coordination of Benefits
What is in the best interest of my overall health & wellbeing?
Does my existing coverage meet all of my needs?
The only time you can get back on this student plan is on the anniversary of opting out of the plan OR within 30 days of losing your alternate coverage.

Proof of Comparable Coverage

You are required to provide proof of your comparable extended health and dental coverage by attaching documentation displaying the policy information when you are completing the online form.

Confirmation of coverage must show the name of the insurance company providing the coverage and the policy number. Acceptable forms of confirmation of coverage are:

Copy of a Plan Card (front and back images).
Confirmation letter from the employer or insurance company with a current date.
Recent health care claim statement with the current date (within 3 months of application submission).
Webpage printout with a visible current date.

Important notes:

The Manitoba Health Services Insurance Plan or The Student Plan is not acceptable as comparable insurance coverage.
Students with comparable coverage can choose to opt out of health, dental, or both.
The comparable coverage accepted could be from parents, spouse, work, government, or band.
Approval of the Students opt-out will result in the plan fee being refunded according to the school's policy. The Opt-Out result is a one-time process. This means students do not need to apply every term or year.
NO EXCEPTIONS will be made if the deadline is missed. It is the student's responsibility to pay the plan's mandatory fees, should they miss the applicable opt-out deadline.
Once you complete the opt-out form, you will receive an automated email confirmation. Please keep this email for your records as it is your only proof of submitting an opt-out request.

Steps to submitting a Health and Dental Opt-Out Application:

1 Student Information

Complete this section below providing true and correct information. Click NEXT.

2 Health Plan Opt-Out

Scroll down and check yes/no if you wish to opt-out of the health portion of the student plan. Provide the alternate insurance company name and policy number. Click NEXT.

3 Dental Plan Opt-Out

Scroll and check yes/no if you wish to opt out of the dental portion of the student plan. Provide the alternate insurance company name and policy number. Click NEXT.

4 Read and Agree to the Terms and Conditions

Click on the checkbox to indicate that you agree to the Terms and Conditions agreement. Click SUBMIT to finish your application.

5 Confirmation Email

Check your email and verify if you have received the confirmation email. If you do not receive this email, you must resubmit the form.

6 Application Status

You will receive an email with the status of your application within 7-10 business days.

Add donotreply@gallivan.ca to your address book. Please do not reply to this email.

Questions? Please contact your Benefit Plan Office: boothplan@mystudentplan.ca

Health and Dental Opt-Out Form

Please complete all information on the opt out form and we will process your application as soon as we can.

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Date of Birth

Date Month Field Date Day Field Date Year Field

Mailing Address

City

Province

Postal Code

Phone Number

Phone Area Number Phone Local Number Phone Digits

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Required Direct Deposit Information

Please enter your financial institution's Transit Number, Institution Number, and Account Number. (*mandatory fields)

** Please do not enter any dashes or spaces **

Transit #

Institution #

Account #

Winter Deadline
Submit your online Family Add-On, Opt-Out, or Opt-In applications by January 26^th, 2024

Plan Card Generator
Generate your Plan Card and use it where direct billing to Canada Life is available.

Prescription Search Tool
Find out if your prescription drugs are covered by the student plan.

Plan Claims
Learn more about submitting online or manual claims to Canada Life to get your refund.

Booth UC Benefits Plan Office

Email: boothplan@mystudentplan.ca
Address: 447 Webb Place
Winnipeg, Manitoba. R3B 2P2

General Inquiries Line

Monday to Friday from 7:00am to 6:00pm CST

Phone: 1-877-746-5566 Ext. 7249

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