Opt Out Request Form

For UBC International Students already covered by Canadian Provinical Coverage only
Please note: This is not the correct optout form for ELI Students

* = required field
Personal Information
* First Name:
* Last Name:
  Student Number:
* Date of Birth: (mm/dd/yyyy)
* Effective date shown
  on IMED Card:
* Telephone #:
* Email address:
* Program type:
* Indicate why you are requesting to opt out
I am already covered on Health Insurance BC (MSP)
  Indicate the date your MSP coverage began
  I am already covered on the provincial / territorial health plan of
  Effective Date
  *For either of the two reasons above, the following supporting documentation is required:

(MSP card alone is NOT an accepted proof of coverage)
(You are allowed to upload these type of files: jpg, gif, png, bmp, tiff, doc, docx and pdf. We recommend jpg format and maximum file size of 1.5 mb.)
I purchased three months of Advance iMED Coverage directly through DCIS.
  This reason only applies to degree and two-term exchange students. Please attach a copy of your study permit with this form:
(file type requirement same as above)
See the “Opting Out” page of the “Enrolment” section at the iMED Website (www.david-cummings.com/imed) to view submission deadlines for opting out.
If your opt out request is approved, the iMED fee will be credited to your tuition account.