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Group Health Forms

PW_M008883
If you have questions about which form to submit, please call the customer service number listed on your member ID card.  
Health Care
Authorization Forms  
Anthem Individual Authorization Form
Designation of an Authorized Representative
Behavioral Health Release of Information Form
 
Claims  
Anthem Blue Cross and Blue Shield Member Health Care Claim Form
Anthem HealthKeepers offered by HealthKeepers Inc. Member Health Care Claim Form
Anthem HealthKeepers offered by Peninsula Health Care Inc. Member Health Care Claim Form
Anthem HealthKeepers offered by Priority Health Care Inc. Member Health Care Claim Form
Claims Exception Form
 
Membership  
Member Change Form
Notification of Student Status Form
Waiver of Group Health Benefits & Notice of Special Enrollment Rights
 
Transition of Care  
Anthem HealthKeepers Offered by HealthKeepers, Inc. Transition of Care
Anthem HealthKeepers Offered by Peninsula Health Care, Inc. Transition of Care
Anthem HealthKeepers Offered by Priority Health Care, Inc. Transition of Care
 
Pharmacy and Prescription Drug
Prescription Drug Claim Form
Mail Service Pharmacy Order Form
Synagis TM (palivizumab) - Health Services Review Form

(Formerly Synagis Prior Authorization Form)

 
Dental
Anthem Dental Care Claim Form
Anthem Dental Enrollment Application
 
Vision
Blue View Vision Anthem HealthKeepers Member Claim Form
Blue View Vision Anthem Blue Cross and Blue Shield Member Claim Form
Davis Vision Anthem Blue Cross and Blue Shield Member Vision Claim Form
 
©2005-2014 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. 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