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Anthem Blue Cross : Provider Forms

Provider Forms

PW_A115172
IF YOU ARE IN NEED OF ANY ADDITIONAL FORMS PLEASE CONTACT YOUR PROVIDER CONTACT FOR ASSISTANCE.  
Physician Change Form
Allows physicians to notify Anthem Blue Cross of any tax identification number, practice/mailing address, hospital privilege, phone and fax number changes.  
Provider Dispute Request Form  
Anthem Blue Cross Department Contacts Listing  
Claim Follow-Up Form  
Network Provider Pricing Request Form  
Behavioral Health Address Update Form
Allows participating Behavioral Health practitioners to notify Anthem Blue Cross of any tax identification number, practice/mailing address, phone number, fax number and open/closed practice status changes.  
Individual Authorization Form
Complete this form for release of PHI and clinical information from Provider to Company. If member wishes to disclose clinical information and psychotherapy notes, member must complete both the Individual Authorization Form and Psychotherapy Notes Authorization Form. 
Psychotherapy Notes Authorization Form
Complete this form for release of psychotherapy notes from Provider to Company. If member wishes to disclose clinical information and psychotherapy notes, member must complete both the Individual Authorization Form and Psychotherapy Notes Authorization Form.  
Behavioral Health Consent to Exchange Form
Complete this form to exchange behavioral health information with all healthcare providers who are involved in the care of our members. This process fosters sharing of clinical information for comprehensive treatment and continuity of care.  
Behavioral Health Practice Profile
Allows participating Behavioral Health practitioners to update self-reported areas of expertise on file with Anthem Blue Cross.  
Behavioral Health Treatment Plan Form
Complete this form to request authorization for outpatient professional services by a Behavioral Health practitioner, when authorization is required.  
Federal Employees Plans (Member number with an R as the prefix)  
EAP Provider Claim Forms
Allows participating Employee Assistance Program (EAP) practitioners to submit an EAP claim to Anthem Blue Cross  
Recommend a Dentist for the Dental Blue Network  
COB 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.