Forms: Health

Below are forms for the Health plan. For the forms pertaining to more than one benefit plan, please refer to the:

Human Resources Benefits Forms Page.

Newly eligible faculty & staff may conviently elect to or waive healthcare coverage using the eBenefits, HRIS Self Service module.
Benefit Enrollment and Change ( PDF)	After hire, use this form to enroll in the health plan or change the coverage of a spouse or dependent child as a result of a change in family or employment status. Must be submitted within 31 days from the date of the qualifying event.
Benefit Plan Withdrawal Form ( PDF)	Use this form to drop health insurance coverage. Must be submitted within 31 days of a qualifying change in family or employment status.
Retiree Health ( PDF)	Health enrollment form for Retiree and COBRA participants
COBRA Health ( PDF)	Health enrollment form for COBRA and Retiree participants
Same Gender Domestic Partner Relationship Declaration Form ( PDF)	This form is used to declare a same gender domestic partner relationship.
Same Gender Domestic Partner Relationship Termination Form ( PDF)	This form is used to terminate a same gender domestic partner relationship.
Visiting Scholar Health ( PDF)	Health enrollment form for Visiting Scholars
Claim Forms
Blue Cross/Blue Shield Health Claim ( PDF)	To submit, with health service receipts, to your BC/BS health plan provider.
Value PPO Claim Form ( PDF)	To submit, with paid pharmacy receipts to your BC/BS health plan provider.
Walgreens Health Intitiatives Member Reinbursement Claim Form ( PDF)	To submit form, with paid pharmacy & prescription reciepts to WHI for reinbursement of non participating pharmacy claims.
Prescription Drug Mail Order Forms
Walgreens Health Intitiatives Premier PPO/Select PPO Mail Order Prescription Form ( PDF)	If you are a member of either the Premier or Select PPO plan, please use this form to order prescription drugs by mail order.
Value PPO Mail Form ( PDF)	If you are a member of the Value PPO plan, please use this form to order prescription drugs by mail order.
Walgreens Health Intitiatives HMO Illinois Mail Order Prescription Form ( PDF)	If you are a member of the HMO Illinois plan, please use this form to order prescription drugs by mail order.
UniCare HMO Prescription Drug Mail Order Form ( PDF)	If you are a member of the Unicare plan, please use this form to order prescription drugs by mail order.