PW_A117010
Forms
Download Instructions:
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.
|
|
Download
Language Assistance Program
Our complete Notice of Privacy Practices provides a comprehensive overview of the policies and practices we enforce to preserve our members’ privacy rights and control use to their health care information, including: the right to authorize release of information; the right to limit access to medical information; protection of oral, written and electronic information; use of data; and information shared with employers.
Use this form to report termination of employees and/or dependents, address change for covered employees, or COBRA/Cal COBRA notifications.
When completing the Small Group Employee Application and a translator assists you, the translator must complete this form and attach it to the application.
When an employee receives services from a health care provider, the health care provider submits the claim directly to Anthem Blue Cross. However, in certain circumstances the employee may be required to submit a claim form. See page 1 of this form for instructions.
When an employee receives services from an in network vision provider, the provider will submit the claim for them. However, if services are received from an out of network provider, the employee will need to fill out the vision claim form and submit with a copy of the bill to Blue View Vision.
If an employer offers the domestic partner eligibility option to their employees, and an employee wishes to add their domestic partner to their plan, the employee must complete and submit this form along with an Employee Application requesting enrollment.
