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Forms

PW_004028
Only producers appointed by Anthem Blue Cross and Blue Shield in Maine are authorized to represent Anthem on group and individual products. 
Be sure to protect your clients' Protected Health Information (PHI) by encrypting your PHI email. This website will help you understand how messages will arrive to you and how to retrieve them at no cost to you. You only need to register once, and take only a few simple steps to access the messages. You also can reply to the message securely at no cost to you. The privacy of business communication is important to us, and we want to ensure your information stays private. 
Dental Forms: 
Dental Claim Form
Dental Claim Form (Dental Prime and Complete)
Extra Cleaning Form for Diabetic/Pregnant Members (Dental Prime and Complete)
Anthem Dental Prime and Anthem Dental Complete Producer Services
Anthem Dental Prime and Anthem Dental Complete Employer Services
 
Forms: 
ACS | BNY Mellon Group HSA Addendum
Anthem Group Agreement
Anthem Vision Out-of-Network Claim Form
Beneficiary Election Form to Continue Health Benefits
Blue View Vision Out of Network Claim Form
Certification for a Mentally or Physically Disabled Dependent Child Over Maximum Age
Continuation of Care Form
Claim Form (Medical)
Direct Deposit Form
Electronic Check/ACH Authorization Form
General Notice of Pre-existing Condition Exclusion
Group Health Plan (GHP) Identification Form (HIPAA)
Group Profile Form
Large Group Application for Group Insurance
Lumenos HRA Banking Form
Member Enrollment/Member Change Form
Member Enrollment/Member Change Form (Spanish)
New Group Enrollment Checklist (Groups 1-50)
Off Exchange Employer Enrollment App 2015
Off Exchange Employer Enrollment App 2014
Off Exchange Employee Change Form 2015
Off Exchange Employee Change Form 2015 (Spanish)
Off Exchange Employee Change Form 2014
Off Exchange Employee Enrollment App 2015
Off Exchange Employee Enrollment App 2014
Off Exchange Employee Enrollment App 2015 (Spanish)
Report of Terminations Form
Small Group Application for Group Insurance
Small Group Renewal Date Change Request
Transitional Care Form
W-9 Request for Taxpayer Identification Number and Certification
Your Special Enrollment Rights
 
Pharmacy Forms  
Home Delivery Pharmacy Order Form
Prescription Drug Claim Form
 
©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