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Anthem blue cross enrollment

Anthem blue form 2025

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The document is an Anthem Blue Cross Enrollment Form, which is used for enrolling employees and their dependents in various health insurance plans offered by their employer. It includes sections for selecting types of coverage (medical, dental, vision, life insurance), providing personal information, listing family members to be enrolled, and options for declining coverage. Additionally, it covers COBRA/Cal-COBRA continuation coverage details and requires signatures to confirm the accuracy of the information provided.

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Click ‘Get Form’ to open the anthem blue form in the editor.
Begin by entering the effective date in MM/DD/YY format at the top of the form. This is crucial for processing your enrollment correctly.
In Section 1, select your type of coverage from the options provided. Make sure to choose only those coverages offered by your employer.
Proceed to Section 2 and fill in your personal information, including your last name, first name, social security number, and marital status.
In Section 3, list yourself and all eligible family members who will be enrolled. Ensure that you provide accurate birthdates and social security numbers.
If you are declining any coverage, complete Section 4 by checking the appropriate boxes and providing a reason for declining coverage.
Finally, review all sections for accuracy before signing in Section 10. Your signature confirms that all information is true and complete.

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Versions	Form popularity	Fillable & printable
2017	4.8 Satisfied (81 Votes)
2014	4.3 Satisfied (114 Votes)
2013	4 Satisfied (54 Votes)
2012	4 Satisfied (28 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is Anthem Blue the same as Blue Shield?

Is Anthem the same as Blue Cross Blue Shield? Anthem is part of the Blue Cross Blue Shield group. Blue Cross Blue Shield is made up of independent companies. Anthem is one of these companies.

Is Anthem the same as Blue Card?

BlueCard PPO gives you access to Anthem PPO benefits all across the nation by uniting Anthems network with those of other Blue Cross and Blue Shield licensed companies. In fact, more than 85 percent of all hospitals and physicians throughout the U.S. contract with Blue Cross and Blue Shield Plans.

What is a PMF form for Anthem?

The Provider Maintenance Form (PMF) is used to request changes to existing practice profiles of California physicians, practitioners, professionals and ancillary providers. Change requests should be submitted by the practice manager or a designated person of authority.

Is Anthem Blue the same as Medicare?

Anthems Medicare Advantage HMO plans, formerly MediBlue plans, help you save money with no or low plan premiums. Choose an Anthem HMO plan if you want all-in-one coverage that includes Original Medicare (Medicare Parts A and B) and usually Medicare Part D (prescription drug) coverage.

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