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anthem difference plans & benefits Health & wellness

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Applications
Changes to Benefits
Enrollment
Document NameType 
Colorado uniform employee application for small group health benefit plans Expand
Health small group enrollment form
PDF Download
Colorado uniform employee application for small group health benefit plans (en Español) Expand
Health small group enrollment form (en Espanol)
PDF Download
Employee enrollment and change form - specialty products 2-50 member small groups Expand
Employee enrollment and change form - specialty products for small groups members in Colorado
PDF Download
Employee enrollment and change form - specialty products 2-50 member small groups (en Español) Expand
Employee enrollment and change form - specialty products for small groups members in Colorado (en Espanol)
PDF Download
Employee enrollment application/change form
PDF Download
Employee enrollment application/change form (en Español)
PDF Download
Employee enrollment supplemental form - BeneFits for 1-50 member small groups in Colorado Expand
Employee enrollment supplemental form - BeneFits for small group members in Colorado
PDF Download
Employee enrollment supplemental form - BeneFits for 1-50 member small groups in Colorado (en Español) Expand
Employee enrollment supplemental form - BeneFits for small group members in Colorado (en Espanol)
PDF Download
Employee enrollment supplemental form - BluePreferred AIFJ for 1-50 member small groups in Colorado Expand
Employee enrollment supplemental form - BluePreferred AIFJ for small group members in Colorado
PDF Download
Employee enrollment supplemental form - BluePreferred AIFJ for 1-50 member small groups in Colorado (en Español) Expand
Employee enrollment supplemental form - BluePreferred AIFJ for small group members in Colorado (en Espanol)
PDF Download
Employee enrollment supplemental form - EmployeeElect for 1-50 member small groups in Colorado Expand
Employee enrollment supplemental form - EmployeeElect for small group members in Colorado
PDF Download
Employee enrollment supplemental form - EmployeeElect for 1-50 member small groups in Colorado (en Español) Expand
Employee enrollment supplemental form - EmployeeElect for small group members in Colorado (en Espanol)
PDF Download
Medicare supplement health plan application Expand
Medicare Supplement enrollment form
PDF Download
Member Authorization Form
PDF Download

Enroll in Cobra
Document NameType 
COBRA/state continuation of coverage Expand
Please fill out this form to elect continuation of your coverage through COBRA or State
PDF Download

Payment and Billing
Document NameType 
Checking account automatic premium payment form Expand
Fill out this form in order to set up Direct pay from your Checking Account on your account at Anthem
PDF Download
Credit card premium payment authorization Expand
Fill out this form in order to set up Credit card payments on your account at Anthem
PDF Download

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