MyAnthem
Not registered? Sign up to enjoy secure access to personalized information.
Register Now

Access personalized services and information.

Login
Find a Doctor
Search our provider directory when you need a doctor, hospital, pharmacy or other health care provider.

360° Health®
A total-health solution that surrounds everyone with the help they need to live healthier, feel better and save money doing it.

Learn More

Forms

PW_002689
To better protect your Protected Health Information (PHI), do not transmit these forms through email. 
Dental Forms: 
Dental Claim Form (Flex, Preventive, Preventive Plus and USA Dental)
Anthem Dental Prime and Anthem Dental Complete Forms
 
Forms:  
ACS | BNY Mellon Group HSA Addendum
Application for Group Insurance
Certification for a Mentally or Physically Disabled Dependent Child Over Maximum Age
Continuation of Care
Continuation of Care (en Español)
Electronic Census Sheet
Electronic Check/ACH Authorization Form for Premium Payments
Electronic Fund Transfer (EFT) For Groups
Employee Small Group Off Exchange Enrollment Application
Employee Small Group Off Exchange Enrollment Application (en Español)
Employee Small Group Off Exchange Enrollment Change Form
Employer Small Group Off Exchange Enrollment Application
Enrollment and Membership Change Form
Enrollment and Membership Change Form (en Español)
Enrollment Checklist (1-50 Group Market)
Enrollment Checklist (51+ Group Market)
General Notice of Pre-existing Condition Exclusion
Group Family Health Statement
Group Health Plan (GHP) Identification Form (HIPAA)
Lumenos HRA Banking Form
Medical Claim Form
Out-of-Network Claim Form
Request for Waiver of Coverage
Sold Case Checklist - HSA
Statement of Domestic Partnership
Termination Form
Transition of Care
Transition of Care (en Español)
Your Special Enrollment Rights
 
Pharmacy Forms:  
Home Delivery Pharmacy Order Form
Prescription Drug Claim Form

To find these forms, members must visit the Express Scripts website after login to their health plan site. Click the link in the Refill a Prescription section after login. On the Express Scripts site, select these forms from the Printable Forms section.

 
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use