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Forms, Documents, and Brochures

The following forms and resources are saved as PDFs and available to print and download. For access to additional forms, please log in to your secure account.

Medical Plan Provider Directories

To find a Primary Care Provider (PCP), walk-in or urgent care center, or other medical provider, click on the link with your plan type, below.

Find a Medical Provider

To find a PCP or another type of provider in NH or other New England states, choose one of the following options:

  • Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care & Cost" to begin your search.

  • Or, if you do not have an SEP account, visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the "Find Care" page in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – BPP – then click the "Search" button.
    2. Enter your search information.

Find a Medical Provider

To find a PCP or another type of provider in NH or other bordering New England states, choose one of the following options:

  • Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care & Cost" to begin your search.

  • Or, if you do not have an SEP account, visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the "Find Care" page in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – BTO – then click the "Search" button.
    2. Enter your search information.

Find a Medical Provider

To find a PCP or another type of provider in NH or other New England states, choose one of the following options:

  • Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care & Cost" to begin your search.

  • Or, if you do not have an SEP account, visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the "Find Care" page in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – BPP – then click the "Search" button.
    2. Enter your search information.

Find a Medical Provider

To find a PCP, network retail pharmacy, or another type of provider, choose one of the following options:

  • Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care & Cost" to begin your search.

  • Or, if you do not have an SEP account, visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the "Find Care" page in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – BQE for the Lumenos plan or BPP for the ABHD plan – then click the "Search" button.
    2. Enter your search information.

Find a Medical Provider

To find a PCP or another type of provider in NH or other New England states, choose one of the following options:

  • Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care & Cost" to begin your search.

  • Or, if you do not have an SEP account, visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the "Find Care" page in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – BKA – then click the "Search" button.
    2. Enter your search information.

Find a Medical Provider

To find a PCP or another type of provider in NH or other New England states, choose one of the following options:

  • Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care & Cost" to begin your search.

  • Or, if you do not have an SEP account, visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the "Find Care" page in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – BYV – then click the "Search" button.
    2. Enter your search information.

Prescription Plan Pharmacy Directories

Click on the orange Prescription Plan Pharmacy Directories button below to find participating network retail pharmacies.

To locate CVS Caremark Network Retail Pharmacies:

Log in to your Secure Enrollee Portal (SEP) account and click on the CVS Caremark button, then select "Pharmacy Locator."

To locate Anthem IngenioRx Network Retail Pharmacies:

Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button. Once on the Anthem site, select My Plans > Pharmacy.

Dental Plan Provider Directories

To find a participating dentist in New Hampshire, click on the Dental Plan Provider Directories button below.

Northeast Delta Dental Directory
(Select "Delta Dental Premier" for plan type)

Anthem/IngenioRx Prescription Coverage - For the Lumenos Plan

Anthem IngenioRx Mail Service Order Form [212 Kb]

Benefit Advantage FSA/HRA Services

Change in Status Form [355 Kb]
Direct Deposit Authorization Form [129 Kb]
Election Worksheet [59 Kb]
Enrollee FSA Brochure [1.41 Mb]
FSA Claim Form [101 Kb]
Healthcare Eligible Expenses List [80 Kb]
Physician Statement [317 Kb]
Void & Reissue Form [372 Kb]

Claims

Anthem Subscriber Claim Form [46 Kb]
CVS Caremark Prescription Reimbursement Claim Form [171 Kb]
Northeast Delta Dental Claim Form [747 Kb]

CVS Caremark Prescription Coverage

CVS Caremark Mail Service Order Form [318 Kb]
CVS Caremark Prescription Reimbursement Claim Form [171 Kb]

Life, Long-Term Disability and Short-Term Disability Enrollment

Life LTD STD Fillable Application Form [184 Kb]

Medical and Dental Enrollment

Annuity Deduction Authorization for Medical and Dental Benefits Fillable Form [248 Kb]
Certificate of Tax Dependent Status for a Civil Union Partner [126 Kb]
Certification for a Mentally or Physically Disabled Dependent Child Over Maximum Age [121 Kb]
Dental Application and Change Fillable Form [482 Kb]
Domestic Partner Statement of Termination [227 Kb]
Domestic Partners Affidavit [120 Kb]
Information Update/Correction Form [235 Kb]
Medical and/or Dental Application and Change Fillable Form [357 Kb]
Notice of Divorce, Legal Separation or Dissolution of Civil Union [99 Kb]
Notice of Membership Changes Fillable Form [533 Kb]
Retiree Medical and/or Dental Application and Change Fillable Form [159 Kb]

Medicare Supplemental Plan (Medicomp Three)

Medicomp Three brochure [122 Kb]
Medicomp Three without Prescription Drug Coverage (MCNRX) Election Form [27 Kb]
Retiree ACH Authorization Form Fillable PDF [301 Kb]

Privacy and Security (HIPAA)

HIPAA Authorization to Release Information [36 Kb]
Notice of Privacy Practices [159 Kb]
Request for Accounting of Disclosures [33 Kb]
Request for Confidential Communications [27 Kb]
Request for Restriction on Uses and Disclosures [33 Kb]
Request to Amend a Record [33 Kb]
Request to Inspect Health Information [34 Kb]
Revocation of Authorization to Release Information [29 Kb]
Termination of Restriction on Use and Disclosures [28 Kb]

Slice of Life

2022 Biometric Health Screening Form - ConvenientMD [167 Kb]
Biometric Health Screening Form - PCP [83 Kb]

Wellness Coordinator Forms and Resources

2023 Wellness Coordinator Academy Application [149 Kb]