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Group Forms

PW_M008633
Table of Contents  
Mid-size and Large Group Employee
Group Applications
Dental and Vision
 

Mid-size and Large Group

Description of Special Enrollment Rights
Disclosure Authorization Form
Member Change Form
HealthKeepers Member Claim Form
Notification of Student Status Form
Online Bill Pay
Waiver of Group Health Benefits & Notice of Special Enrollment Rights
 

Group Applications

HMO/PPO Group App large group mid size market Effective January 1 2016
HMO PPO Group App 100+ Effective January 1 2016)
Employee Enrollment Application (51+)
 
 

Dental and Vision

Anthem Dental Enrollment Application
Anthem Dental Prime and Anthem Dental Complete Forms & Materials
Anthem Dental Care Claim Form
Anthem Dental Prime and Anthem Dental Complete Employer Forms
Blue View Vision Anthem Blue Cross and Blue Shield Member Claim Form
Blue View Vision Anthem HealthKeepers Member Claim Form
 

Prescription, Drug and Pharmacy

2012 Medicare Creditable Drug Coverage
Home Delivery Pharmacy Order Form
Prescription Drug Claim Form

To find these forms, members must visit their health plan website. Select the Customer Care tab in the upper right corner of the page, select the state, and then select Download Forms.

Synagis TM (palivizumab) - Health Services Review Form
 

Massachusetts Minimum Creditable Coverage (MA MCC)

Small Group (2-99) Health Plans Virginia 2012 Massachusetts Health Care Reform Creditable/Non-Creditable Comparison
Large Group (100+) Health Plans Virginia 2012 Massachusetts Health Care Reform Creditable/Non-Creditable Comparison
2012 Non-Marketed Group Standard Health Plans
 

Health Savings Accounts

Mellon Integrated Materials for Lumenos HSA  
Employer Enrollment Guide
HSA Companion Document
HSA Agreement
 
HealthKeepers HDHP (non-integrated HSA) Materials  
ACS BNY Mellon Funding Guide
Discovery Document
Enrollment Engine User Guide
HSA Decision Guide
HSA Employee Non-integrated Overview
HSA Employer Non-integrated Overview for Employers
HSA FAQs
HSA Product Profile
HSAs: A Healthy Investment
Investment Options
Set-up Steps
 
Chase HSA Forms  
Chase Group Initiation Form
Chase HSA Investment Choices
Chase HSA Investment Service Description
Chase HSA Account Holder Brochure, Invest in your health (PNA-212)
Chase HSA Employer Group Initiation Form (PNA-113)
Chase HSA Group Participant Enrollment form (PNA-214)
Chase HSA Group Participant with Individual Enrollment (PNA-216)
 
 
©2005-2017 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use