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PW_M008633

Table of Contents

Small Group (2 to 50 Employees)

Large Group (51 or More Employees)

Dental and Vision

Prescription, Drug and Pharmacy

Health Savings Accounts

Small Group (2 to 50 Employees)

Description of Special Enrollment Rights

Disclosure Authorization Form

Employee application for groups with 15 or more enrolled employees. (The employee is also required to attach a completed Medical Profile when submitting this form at initial group enrollment for employees for groups with 15- 25 contracts.) Instructions in Spanish

Employee Enrollment Application (15+)

Employee Enrollment Application (2-14)

Mail Service Pharmacy Order Form

Medical Profile

Member Change Form

Notification of Student Status Form

Online Bill Pay

Small Business Eligibility Form

Waiver of Group Health Benefits & Notice of Special Enrollment Rights

Large Group (51 or More Employees)

HMO Group Application (2-99)

HMO Group Application (100+)

PAR/PPO Group Application (2-99)

PAR/PPO Group Application (100+)

Dental and Vision

Anthem Dental Enrollment Application

Anthem Dental Prime and Anthem Dental Complete Forms & Materials

Anthem Dental Care Claim Form

Anthem Dental Prime and Anthem Dental Complete Employer Forms

Blue View Vision Anthem Blue Cross and Blue Shield Member Claim Form

Blue View Vision Anthem HealthKeepers Member Claim Form

Prescription, Drug and Pharmacy

Mail Service Pharmacy Order Form

Prescription Drug Claim Form

Synagis TM (palivizumab) - Health Services Review Form

Health Savings Accounts

Chase HSA Account Holder Brochure, Invest in your health (PNA-212)

Chase HSA Employer Group Initiation Form (PNA-113)

Chase HSA Group Participant Enrollment form (PNA-214)

Chase HSA Group Participant with Individual Enrollment (PNA-216)

Chase

Chase Group Initiation Form

Chase HSA Investment Choices

Chase HSA Investment Service Description

Chase Participant Enrollment Form

ACS BNY Mellon

ACS BNY Mellon Funding Guide

Discovery Document

Enrollment Engine User Guide

HSA Decision Guide

HSA Employee Non-integrated Overview

HSA Employer Non-integrated Overview for Employers

HSA Product Profile

HSAs: A Healthy Investment

Investment Options

COBRA

Anthem Blue Cross and Blue Shield COBRA eligibility form

HealthKeepers, Inc. COBRA eligibility form

Peninsula Health Care, Inc. COBRA eligibility form

Priority Health Care, Inc. COBRA eligibility 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. 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