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Forms Library

PW_AD089370
Anthem provides you with the following forms to help you take care of our members. 
 

Claims and Billing
     
Title Form No. Rev Date Format
   
PDF 
 
01/01/09 
PDF 
CMS1450 
 
PDF 
CMS1500 
02/12 
PDF 
INW1226 
03/13 
Word 
 

Grievances and Disputes
     
Title Form No. Rev Date Format
INW1245 
03/13 
Word 
INW1210 
03/13 
Word 
INW1217 
03/13 
Word 
INW1221 
05/13 
Word 
 

Changes and Referrals
     
Title Form No. Rev Date Format
INW1211 
03/13 
Word 
INW1227 
02/13 
Word 
INW1220 
03/13 
Word 
INW1218 
03/13 
Word 
INW2212 
03/13 
Word 
 

Clinical and Preventive Care Tools (Chart Forms and Resources) 
     
Title Form No. Rev Date Format
 
03/13 
Word 
Pregnancy Notification Report
This form should only be used when the state's Notification of Pregnancy online process will not accept your patient's information. 
 
03/13 
PDF 
INW1215 
03/13 
Word 
INW1214 
03/13 
Word 
INW1207 
03/13 
Word 
INW0234 
02/11 
Word 
INW1213 
03/13 
Word 
 
10/08 
HTML 
 

Other Forms
     
Title Form No. Rev Date Format
INW2078 
04/13 
Word 
 
04/13 
Word 
0013508 
12/06 
PDF 
INW1223 
04/13 
PDF 
INW3055 
04/13 
Word 
 
08/11 
PDF 
INW1224 
04/13 
Word 
 
04/13 
PDF 
INW1116 
04/09 
Word 
 
Last Update: 4/2/2013 Version 7 
©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