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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.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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