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PW_002776
To better protect your Protected Health Information (PHI), do not transmit these forms through email. 
Dental Forms  
Anthem Dental Enrollment Application/Change Form
Anthem Dental Employer Application for Group Insurance
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:  
NH 2014 Small Group Census Template (Excel)
ACS | BNY Mellon Group HSA Addendum
Authorization for Automatic Deposits (Credits)
Automatic Debit Transfer Request Form - Group EFT
Benefit Administrator Authorization to Release Information
Benefit Plan Change Form
Certification for a Mentally or Physically Disabled Dependent Child Over Maximum Age
Continuation of Care Form
Domestic Partner Affidavit
Electronic Check/ACH Authorization Form for Premium Payments
Electronic Fund Transfer (Individual Only)
Employment Verification Form
Firm Cancellation Request
Fully Insured Master Contract Signature Page
Group Health Plan (GHP) & Probationary Identification Form
Group Profile and Request for Proposal
High Risk Pool Notice
HRA Agreement
Lumenos HRA Banking Form
Managed Care Member Enrollment/Member Change Form
Managed Care Member Enrollment/Member Change Form (en Español)
Medical Report of Applicant
Medicare Supplemental Selection Form
Medical Risk Disclosure Statement
Member Authorization Form
Member Authorization Form (en Español)
New Business Submission Checklist
New Sale Enrollment Agreement
Notice of Membership Change Form (includes membership additions)
PPO/Indemnity Member Enrollment/Member Change Form
PPO/Indemnity Member Enrollment/Member Change Form (en Español)
Subscriber Claim Form (Medical)
Transitional Care Form
W-4 (Employee's Withholding Allowance Certificate)
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