Forms and Documents

These forms and documents are available as PDF files. Just click on a form or document to download it. You will need Adobe^® Reader^® to view these files; this can be downloaded free of charge at Adobe's site.

If you have medical coverage, the following forms and documents are for you:

Preferred Drug List (PDL)

Mail Service Registration and Prescription Order Form

Member Handbook (includes document of coverage information)

Over-the-Counter Benefits Catalog

Provider Directory (for all medical, dental and vision providers)

Pharmacy Directory

DCFS Youth In Care Program

If you have MLTSS coverage, the following forms and documents are for you:

Member Handbook (includes document of coverage information)

MLTSS Over-the-Counter Benefits Catalog 

Medical Provider Directory (for all medical, specialists and long-term care providers)

Waiver Handbooks

Long-Term Supports and Services (LTSS) Waiver Handbook

Brain Injury Waiver Handbook

Disabilities Waiver Handbook

Elderly Waiver Handbook

HIV/AIDS Waiver Handbook

Supportive Living Waiver Handbook

Additional Documents

Power of Attorney for Health Care Form

Critical Incident Form for Members

Frequently Asked Questions

Multi-language Insert

HIPAA Notice of Privacy Practices

Standard Authorization Form

Authorized Representative Designation Form

Member Rights and Responsibilities