Downloadable Forms for 151+ Employees

ASO
Form Name	Form Number	Date
Employer Enrollment
ASO Benefit Program Application	#HCSC IL GEN ASO BPA	01/14
General Notice of Special Enrollment Rights	#22963	04/15
Notice of Information Practices	#EB4644	03/04
Standard Authorization Form and other HIPAA Privacy Forms	N/A	04/18
Affidavit of Domestic Partnership	#20551	01/05
Statement of Termination of Domestic Partnership	#20560	02/07
Tax Information on Health Benefits for Domestic Partnership	#20559	02/07
151+ Employee Application & Policy Change Form	#20005	11/14
151+ Employee Application & Policy Change Form - Spanish	#228157	11/14
Medicare Secondary Payer (MSP) Employer Acknowledgement Form with Instructions	#240208.0320	03/20
Information Regarding Medicare Secondary Payer (MSP) Statute	#21091.0609	06/09
MSP Fact Sheet (380 kb)	#24443.0612	06/12
Individual Medicare Secondary Payer Form	#20473	10/04
Enrollment Change Request Form	#22735	06/10
Account Maintenance and Supply Forms
Group Administrator's Member Transaction Form	#20406	06/10
Student Certification Form	#23402.0611	06/11
Dependent Student Medical Leave Certification Form	#23077.0111	01/11
Disabled Dependent Authorization Form (for Group Plans)	#238412.0819	08/19
Medical Claim Form (Domestic) – Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.	228934.1015	10/15
Medical Claim Form (Domestic) – Spanish	229421.0116	01/16
Medical Claim Form (International) – Members should use this claim form to request reimbursement for health care services obtained when traveling internationally – when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.	16-581-N35
Medical Claim Form (International) – Spanish	16-581-N35
COBRA Election Form
COBRA Notification Form