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PW_A072236

General Forms

Medical Claim Form and Instructions

Prescription Drug Claim Form and Instructions

Mail Service Pharmacy Order 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.

Notice to Applicant Regarding Policy Replacement
Attention Brokers: This form must be submitted with all individual products applications submitted on/after 05-01-06. Failure to do so may impact the timely processing of the application.

Health Plan Description Forms

Colorado BluePreferred PPO for Individuals Roll-up Form

Colorado Medicare Supplement Plans: Coverage Options

Enrollment Applications and Change Forms

Colorado Individual Enrollment Application/Change Forms
For individuals and their families who are not part of an employer or group coverage.

*Please note: The above application was recently updated with a new mailing address. New address for this application is:

Individual Underwriting
Anthem Blue Cross and Blue Shield
PO Box 9041
Oxnard, CA 93031-9041

Anthem Blue Dental PPO Individual Enrollment Application

Medicare Supplement Health Plan Application
Application form for individual Medicare Supplement enrollees.

Checking Account Automatic Premium Payment Form
Application form for individuals to elect automatic payment of health premiums directly from a checking account.

Credit Card Premium Payment Authorization
Application form for individuals to elect automatic payment of health premiums, or to make initial payment by credit card.

Affidavit of Common-law Marriage - For adding a common-law spouse and his/her dependents to a policy. Download this form in Spanish

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©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