Agents/Brokers

Individual Forms and Tools.

For New Sales
To view the most up-to-date Individual Medical brochures, rates and applications, please go to these locations:
· Order Supplies under Important Tools on the agent home page
· New PPACA-Compliant Plans and Information under Everything Individual on the agent home page.

These forms and documents are stored in the PDF format. In order to view and print these forms, you must have Adobe Acrobat Reader. This software is available for FREE from the Adobe Acrobat Web Site.

Forms	Form #	Revised
Late Enrollee Questionnaire	N/A	10/10
Addendum to Individual Application (Broker Attestation Form)	CAINDATT	05/10
Language Assistance Form to accompany the Individual Enrollment Application	MCASH6334CML	01/09
Change of Coverage Application	3953	01/11
Individual Life Application Change Form	ALCA-IND 5000	10/09
Individual life Change of Beneficiary Form	MCAFR2698B	02/08
MRMIP Request Form	MCAFR2767C	03/08
HIPAA Authorization for Applicants Only	9680	06/08
HIPPA Authorization for Members Only	MCASH2828C	05/08
Payment Request form for Members	N/A	N/A
Checking Account Automatic Premium Payment Form	MCABR2693C	04/11
Summary Bill Request	MCAFR3442C	07/08
Member Claim Form	14150CAMENABC	09/10
Prescription Claim Form	N/A	N/A
Formulary List	N/A	N/A
CoreGuard/ClearProtection Formulary List	N/A	N/A
HealthyCheck	N/A	N/A


	Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Ž ANTHEM is a registered trademark. Ž The Blue Cross name and symbol are registered marks of the Blue Cross Association.