Anthem Forms for the University of Colorado Members

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While providers contracted with Anthem Blue Cross and Blue Shield will file claims on your behalf, there may be cases where you need to file a claim directly with Anthem for reimbursement. For those cases, we have included a claim form that can be submitted by members. 
 
Below, please find a special claim form for flu shots. You may use this form if you obtain your flu shot during the flu season at local pharmacies and other community sites that do not file claims directly with Anthem and require payment at the time of service. We have also included a special claim form for health screening services you may receive at health fairs from time to time. Typically, providers at health fair screenings outside your physician offices do not bill to the insurance companies on your behalf and require payment when services are rendered 
 
Should you need to have Anthem release your medical information to anyone you may designate, we have also included release forms. 
 
For any forms related to eligibility in the Anthem medical insurance plans, please see your Benefits Office. 
Anthem Forms 

Out-of-Network Vision Claim Form

Continuity of Care Form

Flu Shot Clinic Form - for new and renewal plans 1/1/07 and after

Health Fair Claim Form

Medical Claim Form and Instructions

Retail RX Claim Form

CU Mail Order Prescription Claim Form

Individual Authorization Form - This form authorizes Anthem to release a member’s medical information to the person listed on the form.

Psychotherapy Notes Authorization Form - This form authorizes Anthem to release a member’s psychotherapy notes to the person listed on the form.

International Travel Claim 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. 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