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Download Commonly Requested Forms
PW_014873
Please send enrollment maintenance correspondence to
P.O. Box 37730
Louisville, KY 40233-7730
Anthem Fact Sheet
Home Delivery Order Form (medications)
Tax Documents for New Groups Without a Wage and Tax
Sample Explanation of Benefits
New RX Options for HMO and PPO Products
Medicare Secondary Payer Form – Employer
Medicare Secondary Payer Form – Employee
Prescription Drug Claim Form
Anthem’s Billing Process
Pre-ex General Notice (Midwest)
Description of Special Enrollment Rights
PCP Selection Form
Affiliated Companies
Anthem Electronic Funds Transfer (EFT)
Mellon HSA Solution Transfer Form
Dental Member Nomination Form for Additional Cleaning
(applies to dental plans with integrated dental):
Diabetic Form
Mothers-to-be Form
Member Welcome Letters:
Benefit Administrator Transmittal Letter
BlueAccess
SM
Welcome Letter
BluePreferred® Primary Welcome Letter
BluePreferred® Primary Plus Welcome Letter
BluePriority® Welcome Letter
BlueTraditional® Welcome Letter
ASO
Employee Change Form Application A-78
Anthem Enrollment Application A-77
Anthem Enrollment Application A-77 SP (Spanish)
Employer Application for Administrative Services CR ASO
Large Group Forms
Lumenos HSA Addendum for 51+ (ECESH1660A)
Large Group Quote Forms and Cost Share Option Sheets
Large Group Employee Application (Group Size 51-99) AKY-81
Large Group Employee Application (Group Size 100+) AKY-82
Large Group Employee Application A-82 – Spanish Version
Large Group Employer Application CR-101
Employee Change Form Application AKY-83
Employee Change Form Application A-83 – Spanish Version
Small Group Forms:
Small Group (2-50) Renewal Benefit Change/Reclass
Small Group Quote Forms
Small Group Employee Application AKY-216
Employee Application (Group Size 2-50) A-216-SP (Spanish)*
Small Group Employer Application A-100
Employee Change Form Application A-83
Employee Change Form Application A-83 - Spanish Version
Termination Form
Helpful Hints – Small Group Enrollment Application
Anthem Electronic Funds Transfer (EFT) for Small Group Lumenos HRA
Medicare Secondary Payer – Association Small Group Election Form
Small Group Deductible Credit Form
Blue View Vision Out-Of-Network Claim Form
Group Contact Information:
Kentucky Large Group Contact Information
Kentucky Small Group Contact Information
Individual Forms:
Midwest Individual Applications
