Check one Yes No CLAIM FORM
See reverse side . and the Medical Information Bureau and their representatives to give Anthem Blue Cross and .
MEDICAL INFORMATION PATIENT INFORMATION SUBSCRIBER INFORMATION (on Anthem Blue Cross Card) Member Claim Form Please use a separate claim form for each patient.
Claim Form
Member Claim Form Please use a separate claim form for each patient. Your cooperation . SIDE FOR COMPLETE INSTRUCTIONS PATIENT INFORMATION SUBSCRIBER INFORMATION (on Anthem Blue Cross .
Member Claim Form Please use a separate claim form for each patient. Your cooperation in completing all items on the claim form and attaching all required documentation will .
One patient and one provider per claim form. See next page for claim filing instructions. 13551COMENABS Rev. 3/11 Anthem Blue Cross and Blue Shield is the trade name of Rocky .
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Blue View VisionSM Out of Network Claim Form. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. An independent licensee of the Blue Cross and .
1 Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. � ANTHEM is a registered trademark of Anthem Insurance .
MeDicAL cLAiM FoRM inStRUctionS : Please send claims to: Anthem Blue Cross and Blue Shield P.O. Box 105187 Atlanta, GA 30348-5187 Anthem Blue Cross and anthem blue cross claim form Blue Shield is the .
Anthem Blue Cross and Blue Shield is the trade name of Anthem Health . Blue Shield Association. � Registered marks Blue Cross and Blue Shield Association. Out-Of-Network Claim Form .
Please use a separate claim form for each patient. Your cooperation in completing all items on the claim form and attaching all required documentation will help expedite quick
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