How to Enroll

A new enrollment form is required every year.

Follow the steps outlined on this page for enrollment.

You will need Adobe Acrobat^TM software to print out and complete the PDF enrollment form. If you do not have Adobe Acrobat^TM software on your computer, you may download it by clicking on the image below:

Download and print the enrollment form

1. As you complete the form, be sure to:
• Select the Base Plan or the Enhanced Plan.
• Check off Single coverage or Family coverage under the Plan you select.
• Check off the school in which you are a student under the Plan you select.
• If you are electing family coverage, be sure to list your dependents.
• Sign and date the enrollment form.
• An ID card will be mailed to the address indicated on the form.
2. Submit your completed enrollment form to the mailing address, fax number or e-mail address listed below for the school in which you are enrolled:

Jefferson Medical College
Ms. Joyce Muwwakkil
Administrative Assistant
Student Health Care Coordinator
Jefferson Alumni Hall
1020 Locust Street, Suite 157
Philadelphia, PA 19107

Joyce.Muwwakkil@jefferson.edu
Phone: 215-503-8189
Fax: 215-503-7510

Jefferson College of Graduate Studies
Ms. Mary Hom
Jefferson Alumni Hall
1020 Locust Street, JAH M-63
Philadelphia, PA 19107

Mary.Hom@jefferson.edu
Phone: 215-503-0151
Fax: 215-503-6690

Jefferson Schools of Health Professions, Nursing, Pharmacy & Population Health
Diana Kestler
Administrative Assistant
Office of Student Life
130 South 9th Street, Suite 709
Philadelphia, PA 19107

StudentLife@jefferson.edu
Phone: 215-503-8189
Fax: 215-503-9834

Note:
The effective dates for the dental program for the Medical College are August 1, 2011 through July 31, 2012.
The effective dates for all other schools are September 1, 2011 through August 31, 2012.