Below are forms for the Health plan. For the forms pertaining to more than one benefit plan, please refer to Human Resources Benefits Forms Page.
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Health enrollment form for faculty and staff hired during October and November 2006 |
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After hire during October and November 2006, 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. |
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Use this form for declaring domestic partner relationship |
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Verfication of full time student status for 2006 terms of study. Not applicable for 2007 |
Name
& Address Change ( PDF)
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Use to change name and or address with insurance company(s) |
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Health enrollment form for Retiree participants |
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Health enrollment form for COBRA participants |
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Health enrollment form for Visiting Scholars |
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Health enrollment form for LOA participants |
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To submit, with health service receipts, to your
BC/BS PPO health plan provider. |
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Use this form to drop health coverage |
| Prescription Drug
Mail Order Forms |
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Use this form to register and order a prescription drug by
mail order. Applicable to Aetna HMO members. Not applicable for 2007. |
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Use this form to register and order a prescription drug by
mail order. Applicable to PPO members. |
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Use this form to register and order a prescription drug by
mail order. Applicable to HMO Illinois members. |
| Prescription Drug
Claim Reimbursement Forms |
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Use this form to request reimbursement from Walgreens Health
Initiatives for a prescription paid out of pocket. Applicable
to Aetna HMO members. Not applicable for 2007. |
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Use this form to request reimbursement from Walgreens Health
Initiatives for a prescription paid out of pocket. Applicable
to PPO and HMO Illinois members |
Health Plans
Summary Plan Description