Forms
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does not provide Technical Support for Acrobat Reader Software. For
technical support, please contact Adobe.
To use these forms:
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4. Fill out the printed form.
5. See the form for specific mailing information.
Download
Member Claim Form
Usually providers of health care bill Anthem blue cross directly
for services to you and your enrolled dependents. However, if you have
to submit a claim for medical services you must complete this form.
Please see page 2 of this form for instructions on how to complete this
form and submit it to Anthem blue cross.
Individual Enrollment Application
Complete this form for any of the following reasons.
-To add a dependent to your contract whose age is
over 60 days from birth.
-If you are enrolled in a California Care (HMO)
or Basic Hospital (PPO) plan and want to change to a different plan.
-Give to a friend or relative would like to enroll in a Anthem blue cross Plan.
If the dependent you want to add to your contract is
a newborn (i.e. under 60 days old), you can add him/her to your contract
by contacting us at the customer service number listed on your ID card,
or by sending us a written request. Please include the policies primary
member ID number, full name of newborn, date of birth and gender. You
may fax this request to Membership Services at (805) 480-8813.
Exceptions to Standard Enrollment
The signature dates on the Individual Enrollment Application or
Change of Coverage Application are valid for 30 days. If,
when your application is being processed, the signature date(s)
exceeds 30 days, you will be required to complete and submit this
form. This usually happens when you sign the application long before
you mail it to Anthem blue cross.
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Life & Disability Forms
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