Anthem Blue Cross Blue Shield Health Insurance  
Care Management Referral Form

If one of our members has needs that require immediate intervention by a case manager, please call 1-800-231-8254, or fax to 1-800-447-5523, or email


 Required field.

1. Patient's Name
  Last Name:  
  First Name:  
2. Certificate Number/Anthem ID Number:
3. Date of Birth (MM/DD/YYYY):
  Month:  Day:  Year:
4. Address
  Street 1:  
  Street 2:  
  Zip Code:  
5. Home Phone Number:
 Area Code: (  )  Phone:  -
6. Work Phone Number:
 Area Code: (  )  Phone:  - Ext: 
7. Good Time to Call:
8. Physician Name:
9. Have you discussed case management with your patient?
   Yes No
10. Health Status/Reason for Notification:




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Anthem Blue Cross and Blue Shield

is the trade name for the following: In Connecticut: Anthem Health Plans, Inc. In Colorado, Rocky Mountain Hospital and Medical Service, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky. In Maine: Anthem Health Plans of Maine, Inc. In Missouri: RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC) and HMO Missouri, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi) and Compcare Health Services Insurance Corporation (Compcare). Independent licensees of the Blue Cross and Blue Shield Association. Serving residents and businesses in Indiana, Kentucky, Missouri, Ohio, Wisconsin, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web sites constitutes your agreement with our Terms of Use.

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