PROVIDER MAINTENANCE FORM - Anthem Health Insurance 2025

1. Click ‘Get Form’ to open the PROVIDER MAINTENANCE FORM in the editor.
2. Begin with SECTION A: GENERAL INFORMATION. Fill in your Primary Care Provider or Specialist details, including your name, group practice name, and Tax ID. Ensure all fields are completed clearly.
3. Move to SECTION B: REASON FOR SUBMITTING FORM. Indicate the effective date and check the appropriate box for your request (add, change, cancellation). Provide a brief description of the reason for submitting this form.
4. In SECTION C: PROVIDER INFORMATION, enter your full name, SSN, specialty, and acceptance status for new members. If applicable, include previous names for changes.
5. Complete SECTION D: ADDRESS with both practice and billing addresses. If you are changing an address, ensure to fill out SECTION E as well.
6. If adding or deleting office locations, fill out SECTION F accordingly. Include any new Tax ID numbers if necessary.
7. In SECTION G: COVERING PHYSICIANS, indicate whether you are adding or deleting covering physicians by providing their names and degrees.
8. Finally, complete SECTION H: CONTACT SIGNATURE by entering your contact information and signing the form before submission.

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