Blue Access for Employers

Dependent Student Medical Leave Form

Members are required to use this form to request a medical leave of absence for a dependent. Completed and signed forms can be returned via mail to:

Blue Cross and Blue Shield of Illinois
PO BOX 805107
Chicago, IL 60680-4112

This form should be used for student medical leaves covered under Public Law 110-381, also known as "Michelle's Law", and student medical leaves covered under Illinois' Public Act 095-0958.

Dependent Student Medical Leave Certification Form