GF-FRM-0117-001
Student Health Verification Form
GEHA has developed this form to help members verify their eligible dependent’s creditable
insurance coverage.
Student information
Student name: Date of birth: / /
MM DD YYYY
School: Graduation year:
Insurance information
Insurance name:
Group number: Effective date of plan:
Subscriber name:
Relationship to student:
The insurance plan meets the following requirements:
1. The plan has an unlimited benefit maximum.
2. The plan has the following calendar year deductibles:
• Elevate (in-network): $500 Self Only; $1,000 Self Plus One; $1,000 Self and Family
• Elevate Plus (in-network): $0 Self Only; $0 Self Plus One; $0 Self and Family
• High Deductible Health Plan (HDHP) (in-network): $1,500 Self Only; $3,000 Self Plus
One; $3,000 Self and Family
• High Option: $350 Self Only; $700 Self Plus One; $700 Self and Family
• Standard Option: $350 Self Only; $700 Self Plus One; $700 Self and Family
3. The plan has a Preferred Provider Organization (PPO) that offers fee-for-service plans with
certain hospitals and other health care providers both domestic and international.
Standard Option, High Option, HDHP
Aetna Signature Administrators
Group number GEHSFD
Alaska, Arizona, California, Connecticut, Georgia, Kentucky,
Maine, Massachusetts, Michigan, Nevada, New Hampshire,
New Jersey, New York, Oregon, Pennsylvania, Rhode Island,
Vermont, Washington
UnitedHealthcare Options PPO
Group number 78-360001
Alabama, Arkansas, Colorado, District of Columbia,
Delaware, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas,
Louisiana, Maryland, Minnesota, Mississippi, Missouri,
Montana, Nebraska, New Mexico, North Carolina, North
Dakota, Ohio, Oklahoma, South Carolina, South Dakota,
Tennessee, Utah, Virginia, West Virginia, Wisconsin,
UnitedHealthcare Choice Plus
Group number 78-360001
