CHIP Logo
Illinois Comprehensive Health Insurance Plan
Pat Quinn, Governor
Andrew Boron, Chairman of the Board of Directors
Melissa Hansen, Executive Director
A State health insurance program for Illinois residents

+ Utilities
+ Administrators
Blue Access for Members (Medical)
Catamaran (Pharmacy Benefit Manager)

Downloadable Documents

These documents have been created using the most recent version of Acrobat. If you experience problems downloading them, before you telephone our office, try downloading the most recent version of Adobe Reader™, and then try the download. If you still experience difficulties, telephone our office or e mail the Webmaster.

Get Adobe Reader

Apply for Coverage:

Apply online

Downloadable Application for Printing

Application - Revised 1/14

Tobacco Use Certification Forms

If your tobacco use has changed, use the Change of Tobacco Use form. (Updated 1/2012)

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
Bank Service Plan (BSP) Form Rev 2/13

Forms for Current Members Only
Mailings to All CHIP Participants Regarding the Affordable Care Act (ACA) 6/18/13)
Continued Eligibility Form - Rev 9/2013
Claim Form
Authorization Regarding Premiums Notices Form Rev 3/13
Special Bank Service Plan (BSP) Form Rev 6/13
Name and Address Change Form - Rev 9/13
Residency Affidavit (PDF) - Rev 9/13
Form for Active Members to terminate their CHIP coverage - Rev 1/13

Plan Information and Rates
List of Hospital PPO Providers - Effective 07/14
Summary of CHIP Coverage - Rev 4/13
ICHIP Premium calculator Calculate your own premiums
Premium Rate Tables - Rev 01/14
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 6/12
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 03/14

Annual Reports and Audits
See the Annual Reports and Audits page

Legislation
Spousal Continuation (Illinois)
Comprehensive Health Insurance Plan Act


Tel 217-782-6333 | Toll Free (Illinois only) 866-851-2751 | TTY 855-691-7156
© Copyright 2013 Illinois Comprehensive Health Insurance Plan All Rights Reserved
Privacy Statement | Legal Disclaimer | Contact Us | Secure Login | RSS Feed RSS Feed
Experiencing a problem with this site? Contact the Webmaster
Health and Human ServicesGetCoveredIllinoisillinois amber alertMissing and exploited children  Bookmark and Share
Images do not depict actual participants or employees