Anthem Blue Cross :

Anthem BlueCross of California

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Anthem Blue Cross :

PW_A116313

Other Forms and Information

Medical Claim Form	This form can be used by all UC members to submit claims for non participating providers.
Foreign Claim Form	This form can be used by UC members to submit foreign claims.
Disabled Dependent Certification	This form can be used by UC members to submit certification for an unmarried dependent child who is disabled.
Transition Assistance Form	This form should be used by members who are in a course of treatment, or pregnant, whose physician does not participate in the Anthem Blue Cross network, or whose medication is not part of the Anthem Blue Cross formulary.
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 UC 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

NextRx Mail Order Form

® Anthem is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association © 2009 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.