Large Group Forms: For Groups with 51 Employees

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PW_A072238

General Forms

Dental Claim Form

Flu Shot Clinic Form

County Health Pool Health Fair Claim Form

Health Fair Claim Form

County Health Pool Dental Claim Form

County Health Pool Department of Transportation Physical Form

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.

Enrollment Applications and Change Forms

Employee Enrollment Application/Change Form - May be used by employees for enrollment and/or changes in large group health, dental, vision, life and disability coverage. Download this form in Spanish

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

Continuity of Care Form - To avoid disruption for a member currently under a provider’s care; approved on a case by case basis up to 90 days in advance.

Mentally or Physically Disabled Dependent Enrollment Request - Submit with enrollment application if you have an overage physically or mentally disabled dependent.
Download this form in Spanish

Waiver of Insurance - To waive insurance benefits when not using the Employee Enrollment Application/Change Form. Download this form in Spanish

COBRA/State Continuation of Coverage - For requesting continuation of health coverage when a member/dependent coverage is terminated. Download this form in Spanish

Anthem Life Insurance Forms - Use the Anthem Life website to access/download Anthem Life forms (other than enrollment application/change form).

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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