LCSA - Enrollment 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 Re-Enroll Application

Only submit this form if you have previously opted out of the health and dental plan and wish to re-enroll. All new or returning eligible students are automatically enrolled in the benefits plan.

Eligibility Criteria

There are 2 circumstances for re-enrolling in the Student Health and Dental Plan:

1 Program Start Date

Eligible students who previously opted out of the benefits and are attending the school on the anniversary of starting an eligible program and meet the eligibility criteria to be enrolled in the student plan may apply to re-enroll in the plan by the applicable term deadline.

For example:

For students starting in Fall the anniversary would be the following September
For students starting in Winter the anniversary would be the following January
For students starting in Summer the anniversary would be the following May

If you miss the anniversary deadline, your next opportunity to re-enroll would be the next anniversary of starting your program.

Fall 2023 deadline is September 27^th, 2023

2 Loss of Comparable Coverage

Eligible students who previously opted out of the benefits and have lost their comparable insurance coverage may re-enroll within 30 days of losing that coverage.

Proof of losing coverage must be sent to
lethbridgeplan@mystudentplan.ca
after completing this form.

Documentation includes a letter from the insurance carrier or the employer stating the student's name, loss of coverage date, the insurance carrier's name & policy number.

If you miss the loss of comparable coverage deadline, your next opportunity to re-enroll would be the next anniversary of starting your program.

The deadline is within 30 days of losing coverage.

If you do not meet the eligibility criteria to be automatically enrolled in the student plan, please do not complete this form. There is no opt-in to the student plan.

Re-enrollment Fees:

Health	$147.00
Dental	$147.00
Health & Dental	$294.00

Important notes:

Eligible students are automatically enrolled in the Student Health and Dental Plan and do not need to submit a re-enroll form. You will see a health fee and dental fee on your student account to confirm you are enrolled.
The effective date of your coverage is the 1st day of the month your program begins.
There is a 45-60-day validation period from the start of the term. During this time, you would have to pay out of pocket for all eligible Health and Dental expenses and keep the receipts. After the enrollment process is complete, you can submit online claims for reimbursement, and your benefits card will be automatically activated.
NO EXCEPTIONS will be made if the deadline is missed.
Once you complete the Re-Enroll form, you will receive an automated email confirmation. Please keep this email confirmation for your records as the confirmation email is your only proof of you submitting a Re-Enroll request.

Steps to Submitting a Re-Enroll Application:

1 Student Information

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

2 Enrollment Circumstances

Scroll down and check Health Plan/Dental Plan/Qualify. You can choose Health or Dental or both plans. Select your status and Click NEXT.

3 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.

4 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.

5Application Status

You will receive an email with the status of your application.

6Pay the Fees

If your application is approved, payment of the fees can be made using the link provided in the approval email or at the benefit plan office before the tuition deadline.

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

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

Health and Dental Re-Enroll Form

Student Information

Student ID Number

Email Address

Confirm Email Address

First Name

Last Name

Sex

FMU

Date of Birth

Date Month Field Date Day Field Date Year Field

Phone Number

Phone Area Number Phone Local Number Phone Digits

Program Name

Program Start Date

Date Month Field Date Day Field Date Year Field

Online Forms Deadline
Submit your online Family Add-On, Opt-Out, or Opt-In applications by September 27^th, 2023

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.

LCSA Benefits Plan Office

Email: lethbridgeplan@mystudentplan.ca
Phone: 403 320-3202 Extension 5310
Address: Room CE1350
3000 College Drive South
Lethbridge, Alberta. T1K 1L6

General Inquiries Line

Monday to Friday from 6:00am to 5:00pm MST

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

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