Forms

HIPAA Privacy

• Authorization to Release Protected Health Information
• Request for Restriction on Use and Disclosure of Health Care Information and/or Confidential Communication
• Member Record Amendment/Correction

Subscriber Forms

• Automatic Withdrawal Authorization
• Notice of Special Enrollment Rights
• Non-Contraception Benefit Option

Public Entity Forms

• Automatic Withdrawal Authorization

Medical Plan

• Anthem Medical Claim Form
• Anthem International Claim Form

COVID-19 Forms

• Vaccination Screening and Consent Authorization

Prescription Drug Plan

• ESI Claim Form

Dental and Vision Plans

• Delta Dental Claim Form
• NVA Claim Form