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PW_AD079312
Small Group (2-50) 
Employee Change Form (Off exchange)
Deductible Credit Form
Electronic Funds Transfer (EFT)
Employee Application AMO-216
Employee Change Form Application AMO-83
Employee Change Form Application AMO-83 SPA, Spanish Version
Employer Application AMOWI-100
Medicare Secondary Payer – Association Election Form
Off-Exchange EMPLOYEE Enrollment Application: 2–50 Employee Small Groups
Off-Exchange EMPLOYER Enrollment Application: 2–50 Employee Small Groups
Subscriber Termination/PCP Change Form
 
Large Group (51+) 
Electronic Funds Transfer (EFT)
Employee Application AMO-82
Employee Application AMO-82, Spanish Version
Employee Change Form Application AMO-83
Employee Change Form Application AMO-83 SPA, Spanish Version
Employer Application CR-101
Lumenos HSA Addendum
 
Administrative Services Only (ASO)  
Employee Change Form Application A-78
Enrollment Application A-77
Enrollment Application A-77 SP, Spanish Version
ASO Business Associate Agreement
 
Dental 
Anthem Dental Prime and Anthem Dental Complete Employer Services
Extra Cleaning Sign Up Form for Diabetic and/or Pregnant Members (Prime and Complete)
 
Pharmacy 
Home Delivery Pharmacy Order Form
Home Delivery Pharmacy Order Form, Spanish Version
Prescription Drug Claim Form
 
Medicare 
Medicare Secondary Payer Form – Employee
Medicare Secondary Payer Form – Employer
 
Miscellaneous  
Affiliated Companies
Contraceptive Coverage Notice AMK-1330
Sample Explanation of Benefits
 
©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