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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

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©2005-2013 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