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PW_014874
Please send enrollment maintenance correspondence to:  
P.O. Box 37910
Louisville, KY 40233-7910  
 
Affidavit of Dependency for Ohio Group Coverage  
Affiliated Companies  
Anthem Electronic Funds Transfer (EFT)  
Anthem Fact Sheet  
Anthem’s Billing Process  
Description of Special Enrollment Rights  
Employer Letter HB1  
Medicare Advantage and Part D Broker Contract Addendum  
Medicare Secondary Payer Form – Employee  
Medicare Secondary Payer Form - Employer  
Mellon HSA Solution Transfer Form  
Member Letter HB1  
New Group Survey  
PCP Selection Form  
Personal Data Sheet  
Pre-ex General Notice (Midwest)  
Sample Explanation of Benefits  
Transmittal of Application Guide  
Transmittal of Applications Form  
 
Dental Member Nomination Form for Additional Cleaning (applies to dental plans with integrated dental):  
Diabetic Form  
Mothers-to-be Form  
 
Welcome Letters:
Benefit Administrator Transmittal Letter  
BlueAccesssm Welcome Letter  
BluePreferred® Primary Welcome Letter  
BluePreferrd® Primary Plus Welcome Letter  
BluePriority® Welcome Letter  
BlueTraditional® Welcome Letter  
 
ASO Forms:
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)  
Login to MyAnthem Broker/Producer to access your Large Group quote forms  
New Business Group Checklist  
Benefit Change Checklist Group  
Employer Questionnaire  
 
Large Group Applications:
Employer Application CR-101  
Employee Application A-82*  
Employee Application A-82 - Spanish Version  
Employee Application A-82 MU  
51-99 Employee Health Questionnaire  
Employee Change Form Application A-83*  
Employee Change Form Application A-83 - Spanish Version  
*All Applications must include the following:  

Pre-ex General Notice

Description of Special Enrollment Rights

 
Small Group Forms:
Small Group (2-50) Checklist  
Login to MyAnthem Broker/Producer to access your Small Group quote forms  
Small group (2-50) Renewal benefit change/reclass  
Helpful Hints - Small Group Enrollment Application  
Small Group Missing Information Sheet  
Small Group Participation Worksheet  
Subscriber Termination/PCP Change Form  
Anthem Electronic Funds Transfer (EFT) for Small Group Lumenos HRA  
Medicare Secondary Payer – Association Small Group Election Form  
Small Group Deductible Credit Form  
 
Small Group Contact:
OH Small Group Contact Sheet  
 
Small Group Applications:
Employer Application A-100*  
Employee Application (Group Size 2-50) A-216*  
Employee Application (Group Size 2-50) A-216- SP (Spanish)*  
Employee Change Form Application A-83*  
*All Applications must include the following:  

Pre-ex General Notice

Description of Special Enrollment Rights

 
Individual Forms:
Midwest Individual Applications  
 
©2005-2009 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. 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: 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. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite or administer the POS policies. Independent licensees of the Blue Cross Blue Shield Association. ® ANTHEM is a registered trademark. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Serving residents and businesses in Indiana, Kentucky, Missouri (excluding 30 counties in the Kansas City area), Ohio, Wisconsin, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web sites constitutes your agreement with our Terms of Use