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Anthem Blue Cross : Download Forms for Large Groups (51 or more Employees)

Download Forms for Large Groups (51 or more Employees)

PW_A118004
Pooled New Group Paperwork  
Pooled New Group Paperwork
Pooled New Group Paperwork with Lumenos
 
Non-Pooled New Group Paperwork  
Non- Pooled New Group Paperwork
Non- Pooled New Group Paperwork with Lumenos
 
Miscellaneous Forms  
Continuity of Care/Transition Assistance
Disabled Dependent Certification
Domestic Partnership Affidavit
Combined Enrollment Form
HIPAA - Individual Member Authorization Form
Life & Disability Forms
Summary Plan Description
Termination of Domestic Partnership Form
Totally Disabled Employee or Dependent Information Request
 
Dental Member Nomination Form for Additional Cleaning  
Applies to dental plans with integrated dental.  
Diabetic Form
Mothers-to-be Form
 
Claims Forms  
Blue View VisionSM Out-of-Network Claim Form
Dental Claim Form
Flexible Spending Accounts Claim Form
Member Claim Form
Member Claim Form – Spanish
MyIncentive Account Claim Form

Prescription Drug Claim Form
Medicare Part D Prescription Drug Claim Form
To find these forms, members must visit the Express Scripts website after login to their health plan site. Click the link in the Refill a Prescription section after login. On the Express Scripts site, select these forms from the Printable Forms section.

 

® Anthem is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association © 2011 Anthem Blue Cross.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.