Forms

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

Benefit Plan Cancellation Form
Use this form to cancel a benefit program. Please be aware that many plans cannot be terminated except during the Open Enrolment period.

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.

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