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Individual Health Forms

PW_M008903
Applications for Coverage:
To apply for coverage, please visit Individual Health  
 
Forms:
Member Claim Form - #900508 (12/02)
Dental Claim Form - #98668
Express Payment Form
Prescription Drug Claim Form - #e-Aw-4070 Rev. 4/02
Anthem Individual Authorization Form
Behavioral Health Release of Information Form
HIPAA Questionnaire (Underwriting) - #901100.PDF
Replacement Notification - #917080.PDF
Reinstatement Form - #AVA1018
Group Dependent Certification Form - #900823.3
Virginia Standard, Lumenos® HSA Standard and Conversion Products Addition of Dependents Form - #MVAFR1247AEN
Virginia Select, Healthy Virginian, Option I and Option II Products Addition of Dependents Form - #AVA1602
Dependent Information Form - #917101
Conversion of Dependent Form - #MVAFR0864AEN
Policy Upgrade Form - #MVAFR0867AEN
Drug Health Services Review Form - #110912

(Formerly Drug Prior Authorization Form)

Synagis TM (palivizumab) - Health Services Review Form - #111592 (08/04)

(Formerly Synagis Prior Authorization Form)

Product Selection Form for Virginia Standard - #AVA1604
Addition of Dependent(s) Application for Basic BlueCare®, Basic KeyCare®, Essential KeyCare®, Individual KeyCare®, KeyCare Flexible Choice®, KeyCare HSA®, KeyCare HealthSmart®, KeyCare HealthSmart® with Enhanced Drug Benefit, KeyCare Preferred®, Lumenos® Health Incentive Account (HIA), Lumenos® Health Incentive Account Plus (HIA Plus), Lumenos® Health Savings Account (HSA), Virginia Advantage®, and Virginia Basic
Addition of Dependent(s) Application for Virginia Standard, Conversion, Standard I & Standard II
Coverage Change Form For Basic BlueCare®, Basic KeyCare®, Conversion, Essential KeyCare®, Healthy Virginian, Individual KeyCare®, KeyCare Flexible Choice®, KeyCare® HSA, KeyCare HealthSmart®, KeyCare Preferred®, Lumenos® Health Incentive Account (HIA), Lumenos® Health Incentive Account Plus (HIA Plus), Lumenos® Health Savings Account (HSA), Lumenos® Health Savings Account (HSA) Standard, Option I and Option II, Standard I and Standard II, Virginia Advantage®, Virginia Basic, Virginia Select, and Virginia Standard
Product Selection Form for Basic BlueCare®, Essential KeyCare®, KeyCare Flexible Choice®, KeyCare® HSA, KeyCare HealthSmart®, KeyCare Preferred®,Lumenos® Health Incentive Account (HIA), Lumenos® Health Incentive Account Plus (HIA Plus), and Lumenos® Health Savings Account (HSA)
Add/Change Term Life Coverage Form for KeyCare Flexible Choice®, KeyCare HealthSmart®, KeyCare HealthSmart® with Enhanced Drug Benefit, Lumenos® Health Incentive Account (HIA), Lumenos® Health Incentive Account Plus (HIA Plus), and Lumenos® Health Savings Account (HSA)
Important Information About Your Personal Health Care Coverage - AVA1667
Important Information About Your Personal Health Care Coverage (Short Option) - AVA1668

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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