Small Group Forms
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Table of Contents
Health Plan Summary of Benefits
These health plans are available for new and renewing gropus on or after January 1,
| Basic and Standard Health Plans|
| Dental and Visions Benefit Summaries|
These plans are available to groups with 2-50 employees.
| Other Health Summary of Benefits (for renewing business only)|
| Note: The products listed below are no longer available for new business; information is provided for renewing business only. These plans do contain the January 1, 2010 benefit modifications and are effective on the group renewal date. |
Enrollment and Change Forms
Nevada Small Group EmployeeElect Life Plan Renewal Change Request Form
Application and change form for enrolment and/or changes in health, dental, vision, life and disability coverage.
May be used by employees for enrollment and/or changes in health, dental, vision, life and disability coverage.
This form authorizes Anthem to release a member’s medical information to the person listed on the form.
This form authorizes Anthem to release a member’s psychotherapy notes to the person listed on the form.
To avoid disruption for a member currently under a provider’s care; approved on a case by case basis up to 90 days in advance.
Use the Anthem Life website to access/download Anthem Life forms.
For requesting continuation of health coverage when a member/dependent terminates coverage with the group. Spanish version of this form
Anthem Blue Cross and Blue Shield now offers a special package of programs for small group employers who are members of the Las Vegas Latin Chamber of Commerce
Home Delivery Pharmacy Order Form
Prescription Drug Claim Form
To find these forms, members must visit the Express Scripts website after login to their health plan site. Click the link in the Refill a Prescription section after login. On the Express Scripts site, select these forms from the Printable Forms section.
To order supplies please log into Agent Services