Downloadable Documents

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Downloadable Application for Printing
One application document may now be used for Plans 2, 3 or 5
Application - Revised 2/12
Application addendum for TAA Certified or PBGC Certified Individuals 3/11

Tobacco Use Certification Forms
Please read the descriptions carefully to select the proper form.

If you are an active enrollee and became active BEFORE February 1, 2010, use the Certification for Active Enrollee form. (Form must be completed and returned by the date indicated in our correspondence to you.) (Updated 11/5/2010)

If your tobacco use has changed, use the Change of Tobacco Use form. (Updated 11/5/2010)

Informational Brochures
Dislocated Workers - 3/11 -- (en español - 6/10)
ICHIP and HIPAA CHIP - 1/11 -- (en español - 6/10)
TAA-CHIP - 1/11 (en español 6/10)
High Deductible Health Plans - 11/10

Forms for New Applicants
Supplemental Application Regarding Possible Third Party Liability - Rev 6/04
Form to Remove a Pending Application from Consideration for CHIP Coverage

Forms for Current Members Only
Continued Eligibility Form - Rev 5/2011
Claim Form
Authorization Regarding Premiums Notices Form Rev 9/05
Bank Service Plan (BSP) Form Rev 3/26/2010
Name and Address Change Form - Rev 2/12
Deductible Change Request Form - 12/11
Residency Affidavit - Rev 9/04
Form for Active Members to terminate their CHIP coverage (PDF) - Rev 3/11

Plan Information and Rates
List of Hospital PPO Providers - Effective July 1, 2011
Summary of CHIP Coverage - Rev 1/11
ICHIP Premium calculator Calculate your own premiums
Premium Rate Tables - Rev 2/12
Summary of Prior Rate Changes - Rev 10/11
Grievance Procedure

Privacy Forms
Confidential Communications Request Form - Rev 9/04
Disclosure Accounting Request Form - Rev 9/04
Licensed Illinois Insurance Producer Information & Authorization form - Rev 4/12
PHI Access Request Form - Rev 9/04
PHI Change Request Form - Rev 9/04
Privacy Complaint Form - Rev 9/04
Response to Denied Request to Change -Rev 2/04
Restriction Request Form - Rev 9/04
Standard Authorization Form - Rev 10/05

Annual Reports and Audits
See the Annual Reports and Audits page

Legislation
Spousal Continuation (Illinois)