> Patients > STU-DENT REGISTRATION FORM FOR NYU STUDENTS
STU-DENT REGISTRATION FORM FOR NYU STUDENTS
Please note: This form is only for use by NYU Students. If you are not an NYU student and wish to enroll in the plan, please use this form.
Registration Type: New ($235) Renewal ($193)
First Name
Last Name
Phone Number
Email
Date of Birth
Sex Male Female
School
University ID Number (N number, e.g., N12345678)
School Year FreshmanSophomoreJuniorSeniorGrad Student
Address Information
Street Address
Apt #
City
State
Zip
Partner Information
Would you like to register a partner on your plan? Yes No
Registration type: New ($235) Renewal ($193)
Address Information (if different from above)
Dependent Information
Would you like to register a dependent on your plan? Yes No
Registration type: New ($83) Renewal ($83)
Number of New Members x $235.00 =
Number of Renewing Members x $193.00 =
Number of Dependents (Under 16) x $83.00 =
Total Charge:
