Anthem Blue Cross : Forms

Anthem BlueCross of California

PW_A103828

Other Forms and Information

Medical Claim Form	This form can be used by all LANS members to submit claims for non participating providers.
HIPAA Member Authorization Form	The HIPAA privacy rules limits the use and disclosure of a members protected health information (PHI) without an authorization from the individual or their legal personal representative. This form will need to be filled out by the member to designate anyone other than a LANS benefits representative to receive PHI.
How to read your Explanation of Benefits (EOB)	Attached is the EOB brochure which includes a sample EOB and how to locate information on it.

Prescription Drug Claim Form

PrecisionRx Mail Order Form

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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.