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PW_002384

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

Application for Medicare Supplement Coverage

Anthem Vision Member Wallet Card

For Preferred Blue PPO and Lumenos Group Members

Benefit Plan Change Form

Blue Direct: Domestic Partner Affidavit

Blue Direct/Lumenos Individual: Enrollment/Change Application

Blue Direct: Individual Markets Health Statement

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

Dental Claim Form

Domestic Partner Affidavit

Domestic Partner Affidavit - Same Sex

Domestic Partner Affidavit - Opposite Sex

Electronic Fund Transfer

Individual Authorization Form

Individual Authorization Form (Spanish Version)

Individual Authorization to Use or Disclose Psychotherapy Notes

Member Enrollment/Member Change Form

Notice of Dependent Eligibility (Dependent Student Certification Form)

Preferred Blue/Indemnity Member Enrollment/Member Change Form

Subscriber Claim Form

(medical)

Transitional Care Form

(to be used by any new Anthem Blue Cross and Blue Shield in New Hampshire 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)

Prescription Drug Claim Form

Fitness Reimbursement Program

Fitness Reimbursement Program Log Card

Fitness Reimbursement Form

Quit Smoking Reimbursement Form

SpecialOffers@Anthem programs may vary for your health plan. Please contact our customer service department to verify the SpecialOffers@Anthem components of your health plan if you are unsure of them.

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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