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PW_002387

To better protect your Protected Health Information (PHI), do not transmit these forms through email.

Anthem Individual Enrollment/Change Application

Application for Medicare Supplement Coverage

Certification for a Mentally or Physically Disabled Dependent Child Over Maximum Age

Claim Form

Dental Claim Form

Electronic Fund Transfer (For Individuals)

Family Health Statement (For Groups)

Health Statement (For Individuals)

Individual Authorization Form

Individual Authorization Form (Spanish Version)

Individual Authorization to Use or Disclose Psychotherapy Notes

Membership Change Form

Out-of-Network Claim Form

Prescription Drug Claim Form

Statement of Domestic Partnership

Transitional Care Form

To be used by any new Anthem Blue Cross and Blue Shield in Connecticut member who is in active treatment for an acute/chronic condition, or receiving prenatal care during 2nd or 3rd trimester of pregnancy, to ensure continuity of care.

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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