Forms for Downloading

Change Form

• Group Insurance Change Form

Claim Forms

• Cigna Claim Form for QCHP
• Delta Dental Claim Form
• MEDCO Prescription Paper Claim Form
• Eyemed Claim Form

Medco Prescription Mail Order Forms

• Prescription Mail Order Form for Health Alliance Illinois
• Prescription Mail Order Form for Health Link Open Access
• Prescription Mail Order Form for QCHP

Opt-Out & Waiver Forms

• Opt-Out Election Certificate

Opt-Out Financial Incentive

• Financial Incentive Opt-Out Packet (SERS Retirees Only)
• Direct Deposit (SERS Retirees Only)
• Federal W-4 Form
• State of Illinois Withholding Form