Health Benefit 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

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Change of Address and Salary
Complete this form when an employee has either a new salary or a new address.
Other Coverage Information for Other Natural Parent
Complete this form to respond to inquiries about the other natural parent (divorce situations or never married to the other parent of the child)
Probation and Contributory Election Form
Complete this form if you are electing to change your current probation or contributory period for new employees.
Request for Name Change
An employee would complete this form when requesting to change their name, due to divorce, marriage or a court decree.

Creditable Coverage
Creditable Coverage Requirements
Creditable Coverage Requirements Under Medicare Modernization Act (MMA) for Medicare Part D Eligible Members.
Medicare Part D FAQ's
Notice of Creditable Coverage Letter
Important Notice from Christian Brothers Health Benefit Services About Your Prescription Drug Coverage and Medicare

Dependent Forms
Change of Dependent Coverage
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 Children with Disabilities
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 disability, 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.
Dependent Eligibility Form
An employee would complete this form when electing to cover a step child, foster child or child under a legal guardianship arrangement.

Life Insurance and Disability Enrollment Forms   |  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 coverage only.
Open Enrollment Form   |  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   |  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   |  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.
Special Enrollment   |  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)

HIPAA Privacy & Authorization
CBEBT HIPAA Privacy Notice
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
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.
Express Scripts HIPAA Authorization Form
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 or b y sending in a Healthcare Power of Attorney by mail. Only the patient on the account can designate a personal representative.

Leave of Absences
Return From Leave of Absence
Complete this form when an employee has returned back to work, working the eligible hours required for benefits.

Medicare Secondary Payer
Medicare Law Always Applies
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
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
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.
Medicare Supplement Sheet
This document provides an easy reference guide for FAQ regarding Medicare coverage.

Accident Detail Inquiry
An employee or dependent would complete this form to provide details of an accident or injury for which medical expenses have been incurred.
Continuity of Care
Member request form for continuity of care
Divorce Decree Information
Please complete the form to assist us in determining the proper "order of benefits" in divorce situations.
Electronic Payment Information Form
Electronic bank payment form.
Medical Appeal Request Form
An employee would use this form when an adverse benefit determination has been made, which an employee wishes to appeal.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

Reimbursement Forms
Dental Claim
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
Complete this form for non-PPO claims when a standard form of billing is not available. This form should also be used for vision claims.
Prescription Drug Reimbursement
Rx Drug Reimbursement form
Vaccine Reimbursement Form
This form is to be used if a flu shot/vaccine was received at a pharmacy and you were required to pay for it.

Terminations & Leave of Absences
Request for Waiver of Benefits
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)
Statement of Change of Active Employment
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.

Transparency in Coverage - Machine Readable files
The No Surprises Act Transparency in Coverage (TiC) Final Rule requires group health plans to create and publish machine-readable files (MRFs) by July 1, 2022 that contain detailed pricing information including: 1) Network negotiated rates for all items and services, and 2) Historical payments to, and billed from charges from, out-of-network providers.

To be in compliance with the TiC MRF Rule requirement, employers should be prepared to post the below appropriate Preferred Provider Network link on their public-facing website (not on an internal site or benefits portal where it is available solely to the employees or plan participants). There is no formal guidance on how or where the link should be displayed on the website.
Aetna Signature Administrators (ASA) PPO Plans
These files will be updated monthly on the 25th of each month.
Blue Cross Blue Shield of Illinois (BCBSIL) PPO Plans
These files will be updated monthly on the 2nd Tuesday of each month.

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