Downloadable Forms

When mailing these completed forms back to us, please send them to:
Health Benefit Services
1205 Windham Parkway
Romeoville, IL 60446-1679

The forms can also be faxed to us at 630-378-3005 or emailed to us at HBSenrollmenthelp@cbservices.org.
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Changes/Updates
Beneficiary Designation Form (Last Updated: 06/15/2015)
Change of Address and Salary (Last Updated: 12/16/2014)
Complete this form when an employee has either a new salary or a new address.
Other Coverage Information for Other Natural Parent (Last Updated: 12/16/2014)
Complete this form to respond to inquiries about the other natural parent (divorce situations or never married to the other parent of the child)
Other Coverage Update (Last Updated: 12/16/2014)
Complete this form to respond to inquiries regarding other coverages for a covered employee or dependent.
Probation and Contributory Election Form (Last Updated: 05/01/2017)
Complete this form if you are electing to change your current probation or contributory period for new employees.
Request for Name Change (Last Updated: 12/16/2014)
An employee would complete this form when requesting to change their name, due to divorce, marriage or a court decree.


Dependent Forms
Change of Dependent Coverage (Last Updated: 11/03/2015)
Complete this form when an employee wants to drop a dependent or dependents, with the option of electing a continuation of coverage, if eligible.
Dependent Eligibility Form (Last Updated: 12/16/2014)
An employee would complete this form when electing to cover a step child, foster child or child under a legal guardianship arrangement.
Dependent Handicap Status (Last Updated: 12/16/2014)
An employee would need to complete this form if their dependent child that is incapable of self-support as the result of substantial mental impairment or physical handicap, has reached the maximum age as defined in the Plan. Upon an internal review, a determination is rendered as to whether coverage can be continued or denied. If approved, the Trust reserves the right to confirm eligibility in the future.


Enrollments
Life Insurance and Disability Enrollment Forms (Last Updated: 07/12/2017)   |  En Español
An employee would complete this form if the location is only covered with Christian Brothers Employee Benefit Trust for Life and or Long Term Disability coverages only.
Open Enrollment Form (Last Updated: 06/28/2017)   |  En Español
Please use this form during your group's annual open enrollment period, which is the 60 days prior to your renewal date.
Request for Group Coverage Enrollment Form - 2 Tiered (Last Updated: 06/28/2017)   |  En Español
A new employee would complete this form electing or declining the coverage(s) offered by the Employer, for themselves and dependents, within 31 days of eligibility.
Request for Group Coverage Enrollment Form - 4 Tiered (Last Updated: 06/28/2017)   |  En Español
A new employee, only at a location that offers tiered dependent rates, would complete this form electing or declining the coverage(s) offered by the Employer, for themselves and dependents, within 31 days of eligibility.


Enrollments & Dependent Forms
Special Enrollment (Last Updated: 12/16/2014)   |  En Español
Complete this form when an employee and or dependents who were eligible for benefits elected to waive the coverage(s) offered by the Employer, or did not apply within 31 days of eligibility, and now have a qualifying event. The following are considered qualifying events:
  • Loss Of Coverage
  • Newly Acquired Dependent(s) (marriage, birth or adoption)
  • Children’s Health Insurance Program Reauthorization of 2009 (CHIP)(either upon initially becoming eligible or losing coverage)


Leave of Absences
Return From Leave of Absence (Last Updated: 12/16/2014)
Complete this form when an employee has returned back to work, working the eligible hours required for benefits.


Miscellaneous
Accident Detail Inquiry (Last Updated: 11/16/2015)
An employee or dependent would complete this form to provide details of an accident or injury for which medical expenses have been incurred.
Divorce Decree Information (Last Updated: 12/16/2014)
Please complete the form to assist us in determining the proper "order of benefits" in divorce situations.
Medical Appeal Request Form (Last Updated: 04/22/2015)
An employee would use this form when an adverse benefit determination has been made, which an employee wishes to appeal.
Medicare Law Always Applies (Last Updated: 06/13/2018)
This document provides an overview of Medicare Secondary Payer Guidelines as well as an example of how the rule applies based on group size.
Medicare Secondary Payer Form (Last Updated: 06/13/2018)
This form needs to be completed by all employers each year or anytime there is a change in status affecting whether Medicare should be the Primary Payer or the Secondary Payer.
Medicare Secondary Payer Form Instructions (Last Updated: 06/13/2018)
This document provides instructions on how to complete the Medicare Secondary Payer From as well as references to additional if more information is needed about the Medicare Secondary Payer Law.


Privacy
CBEBT HIPAA Privacy Notice (Last Updated: 12/16/2014)
This notice is a summary of privacy practices for Christian Brothers Employee Benefit Trust. It describes how medical information about our member may be used and disclosed and how one can get access to their information.
Christian Brothers Employee Benefit Trust HIPAA Authorization (Last Updated: 12/16/2014)
Authorization form for use or disclosure or Protected Health Information. Complete for members of the family that are over the age of 18 to indicates who is allowed to inquire about their claims/conditions.
Christian Brothers Employee Benefit Trust HIPAA Authorization SP (Last Updated: 12/16/2014)
Autorización para reveler información médica. Este forma debe ser completado por los miembros mayores de dieciocho años para dar permiso a otros miembros de la familia para hablar sobre su información médica.


Reimbursement Forms
Dental Claim (Last Updated: 12/16/2014)
Standard Dental Claim form that can be taken to a dentist’s office to be completed: charges entered and then submitted to our office for claim Pre-Authorization or Payment.
HBS Claim Reimbursement Request (Last Updated: 02/01/2017)
Complete this form for non-PPO claims when a standard form of billing is not available
Prescription Drug Reimbursement (Last Updated: 03/25/2015)
Rx Drug Reimbursement form
Vaccine Reimbursement Form (Last Updated: 10/13/2015)
This form is to be used if a flu shot/vaccine was received at a pharmacy and you were required to pay for it.


RX Plan Info
Express Scripts HIPAA Authorization Form (Last Updated: 12/16/2014)
Express Scripts, Inc. no longer uses a HIPAA form. Requests to designate a Personal Representative can only be processed by submitting the online Designate a Caregiver Form through www.Express-Scripts.com or b y sending in a Healthcare Power of Attorney by mail. Only the patient on the account can designate a personal representative.
Express Scripts Mail Order Form (Last Updated: 12/16/2014)
An employee would use this form to receive ongoing prescriptions via mail order.


Terminations & Leave of Absences
Statement of Change of Active Employment (Last Updated: 11/03/2015)
Complete this form when an employee has changed from an active status, such as termed/resigned, LOA, FMLA, MLOA, LTD, retired, teacher contract ends, and a reduction of hours that would make one ineligible for benefits. The election to continue benefits would also be elected on this form.


Terminations/Waivers
Request for Waiver of Benefits (Last Updated: 12/16/2014)
An employee that is still actively working, however, is electing to waive the optional benefits offered by the Employer. (DO NOT USE FOR NEW EMPLOYEES OR TO DROP DEPENDENT COVERAGE)