Enrollment/Change/Termination Forms
    Download Employee Termination Form (PDF Format)
    Download Anthem Enrollment 2-50 Eligible Employees (PDF Format)
    Download Anthem Enrollment 50 plus Eligible Employees (PDF Format)
    Download Anthem Change Form (PDF Format)
    PreEx General Notice
    Description of Special Enrollment Rights

Continuation of Coverage Forms
    Less than 20 employees - Conversion Privilege Notice
    20 to 50 employees - COBRA/Conversion General Notice
    51 or more employees - COBRA General Notice

Claim Forms
    Medical Claim Form
    Prescription Drug Claim Form

Affidavit of Dependency
Prescription Mail Order Form

Links
  Anthem Web Site
  Member Self-Service
  Provider Directory
  Anthem Prescription Management
  Anthem Prescription Tiered Drug List

Contact Faye Scott, Servicecorp Consultant, or Mary Goshert, Director, Insurance & Financial Services, at  800-285-5300.