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Forms | Health and Welfare

Health and Welfare

The following forms are available to be downloaded to your printer. Once completed, please return them to the Office of Benefits Administration. Please note that additional documentation is often required to accompany some forms. If you do not have Adobe Acrobat on your computer, you may down-load it from the ITS Web site.

Health and Welfare

Certification of Dependent Child Eligibility for Medical and Dental Benefits
This form certifies eligibility of a dependent child over the age of 19 to continue coverage through USC health plans.

Waiver of Coverage
To waive coverage, and be eligible later for Special Circumstances Enrollment if coverage is lost.

Network Plan Medical and Mental Health Claim Form and Plan C Prescription Reimbursement
To submit a claim for the Network Plan for medical or mental health benefits or claim for prescription reimbursement for Plan C participants.

RX America Claim Form
Use this form to make a claim for Prescriptions. Generally used to make claims for prescriptions filled before RX America shows participant as eligible.

Delta Dental claim form
Use this form to make a claim for reimbursement from Delta Dental.

Delta Dental PPO Benefits Highlights
A description of your Delta Dental PPO benefits

Employee Benefit Programs · Health Benefits at USC · Retirement Programs
Financial Security · Educational Benefits · Work/Life Balance
Forms · Coming Events · Directory and Links · Resources
Print Your Own Booklets · Contact Us · Orientation · Site Map · eTrac
USC Benefits Home

Benefits programs are subject to change at anytime by the university, at its discretion, without prior notice or liability, to the extent permitted under applicable law. The benefits described in this Web site are available to staff and faculty employed by the University of Southern California subject to certain eligibility requirements. In the event of a discrepancy between the benefits and limitations described in this Web site and a plan document or a collective bargaining agreement, the terms of the plan document or collective bargaining agreement will govern. Employees of other entities that have entered into agreements with the University of Southern California to provide payrolling service are subject to the policies and procedures adopted by their employer.