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Anthem For Small Business

Documents/Forms for employers

Documents/Forms for employees

ACA

ANTHEM (SB) EMPLOYER APPLICATIONS

Employer Applications:

Combined Medical and Specialty Employer Application

Medical Only Employer Application

 

Forms

  • Cobra, Cal Cobra and Medicare Survey

  • Census Tool Instructions

  • Simple Census 1.99.22

  • Plan Change Request Form

  • Eligibility statement

  • Conditions of Enrollment/Start-Ups/PEO

  • Information Change Form

  • Electronic Debit Payment Form

  • Reinstatement Electronic Debit Payment Form

  • Authorization Request by Phone for Electronic Check/ACH

  • Life Conversion Form

  • Religious Employer Self-Certification Form

  • Employer Access Guide

  • Group Administration Guide

Documents/Forms for employees
 

Employee Applications

  • Combined Medical and Specialty Employee Application

  • Combined Medical and Specialty Employee Waiver Form

  • Employee Application - Spanish

  • Employee Application - Chinese

  • Employee Application - Korean

  • Employee Application - Vietnamese

  • Employee Application - Tagalog

  • Employee Waiver Form - Spanish

  • Employee Waiver Form - Chinese

  • Employee Waiver Form - Korean

  • Employee Waiver Form - Vietnamese

  • Employee Waiver Form - Tagalog

 

Employee forms

  • Custodial Verification Form

  • Handicapped Dependent Certification Form

  • Member Authorization Form

  • Member Authorization Form (Spanish)

  • Member Social Security Number Exception Request Form

  • Statement of Accountability/Translator’s Statement

  • Continuity of Care/Transition of Care Form

  • Continuity of Care/Transition of Care Form (Spanish)

  • Parent Child relationship certification

  • Absolute Assignment Form

  • Evidence of Insurability

  • Evidence of Insurability (Spanish)

  • Beneficiary Designation Form

  • Medical Claim Form

  • Medical Claim Form (Spanish)

  • Medical Claim Form (Chinese)

  • Medical Claim Form (Korean)

  • Medical Claim Form (Vietnamese)

  • Medical Claim Form (Tagalog)

  • Dental Claim Form

  • Prescription Drug Claim Form

  • Prescription Drug Claim Form Spanish

  • Vision Claim Form

  • Accidental Dismemberment or Loss of Sight Claim Form

  • Accidental Dismemberment or Loss of Sight Claim Form (Spanish)

  • Group Life Beneficiary Claim Form

  • Group Life Beneficiary Claim Form (Spanish)

  • Individual Life Claim Form

  • Life Waiver of Premium Claim Form

  • Living Benefit Claim Form

  • Living Benefit Claim Form (Spanish)

  • Long Term Disability (LTD) Claim Form

  • Long Term Disability (LTD) Claim form (Spanish)

  • Short Term Disability (STD) Claim Form

  • Short Term Disability (STD) Claim Form (Spanish)

 

Dental forms

  • Dental Prime and Dental Complete Additional Cleaning Form

  • Dental Blue Additional Cleaning form

  • International Emergency Dental Program flier

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