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PW_014873
Note: Please log in to MyAnthem to find Group Quote forms. 
Small Group (2-50) 
Deductible Credit Form
Dental Essential Health Benefits Opt-Out Form
Electronic Funds Transfer (EFT)
Employee Application AKY-216
Employee Application A-216- SP, Spanish Version
Employee Change Form Application AKY-83
Employee Change Form Application A-83, Spanish Version
Employer Application AKY-100
Medicare Secondary Payer – Association Election Form
Renewal Benefit Change/Reclass
Termination Form
 
Large Group (51+) 
Electronic Funds Transfer (EFT)
Employee Application AKY-81
Employee Application AKY-82
Employee Application A-82, Spanish Version
Employee Change Form Application AKY-83
Employee Change Form Application A-83, Spanish Version
Employer Application CR-101
Lumenos HSA Addendum
 
Administrative Services Only (ASO) 
Enrollment Application A-77
Enrollment Application A-77 SP, Spanish Version
Employee Change Form Application A-78
Employer Application for Administrative Services CR ASO
 
Dental & Vision 
Anthem Dental Prime and Anthem Dental Complete Broker Services
Blue View VisionSM Out of Network Claim Form
Extra Cleaning Sign-Up Form for Diabetic Members
Extra Cleaning Sign-Up Form for Pregnant Members
 
Pharmacy 
Home Delivery Pharmacy Order Form
Home Delivery Pharmacy Order Form (Spanish)
Prescription Drug Claim Form
 
Medicare 
Medicare Secondary Payer Form – Employee
Medicare Secondary Payer Form – Employer
 
Miscellaneous 
Affiliated Companies
Sample Explanation of Benefits
Mellon HSA Solution Transfer Form
 
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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