Download Forms

Adobe Acrobat Reader software is required to view, print and search these PDF documents. Please download this free software on the Adobe Acrobat Web site. Please note that Anthem Blue Cross does not provide Technical Support for Acrobat Reader Software. For technical support, please contact Adobe. 

Adobe Reader 

HIPAA Member Authorization Form and Instructions 

English Version 

Spanish Version 

The HIPAA privacy rules limits the use and disclosure of a member's protected health information without an authorization from the individual or their legal/personal representative. If you desire to share protected health information with another party, please fill out this form and contact customer service at the toll-free number on your member identification card. 

Medical Claim Form 

(Use for vision claims)  

Prescription Drug Claim Form 

If you purchase a prescription drug from a Non-Participating Pharmacy, you will need to submit this form to the Blue Cross Pharmacy Department.  Refer to page 1 of this form for instructions. 

Other Pharmacy Forms 

View a complete list of Pharmacy forms: Prior Authorization of Benefits, Benefit Exclusion, and all Claim forms.