Anthem Blue Cross : Forms

Anthem BlueCross of California

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PW_E183616

Medical Claim Form

HIPAA Authorization Form

Transition Assistance Form

Disabled Dependent Certification

Pharmacy Claim Form – Note: this form is only to be used if you are on the Anthem HMO or HSA plans.

For a full list of forms, visit Anthem's website: anthem.com/ca/forms

® Anthem is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association © 2015 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.