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Forms, Documents, and Brochures

The following forms and resources are saved as PDFs and available to download. Listings marked with an asterisk (*) indicate they are normally carbonless, multi-part forms but cannot be provided as such electronically. Please check the bottom of each of those forms’ pages for a notation regarding their usual color-coded sections and make an appropriate number of copies to distribute accordingly once completed. For access to additional forms, please log in to the secure web portal.

Medical Plan Provider Directories

To find a Primary Care Provider (PCP) or other medical provider, or to view a list of Anthem walk-in centers, urgent care centers and CVS Minute Clinics, click on the link with your plan name, below.

Find a Medical Provider

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

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    Anthem Access Blue New England (HMO) Participating Primary Care Provider (PCP) List

  2. Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care" to begin your search. Or visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    • 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.
    • 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 any of the following options:

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    BlueChoice (POS) Participating Primary Care Providers (PCP)

  2. Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care" to begin your search. Or visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    • 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.
    • 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 any of the following options:

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    Anthem Access Blue New England Site of Service (HMO) Participating Primary Care Provider (PCP) List

  2. Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care" to begin your search. Or visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    • 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.
    • Enter your search information.

Find a Medical Provider

To find a PCP or another type of provider:

Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care" to begin your search. Or visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

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

Find a Participating Pharmacy

To find an Anthem/IngenioRx participating retail pharmacy in New Hampshire, click on the link below.

Anthem NH Retail Pharmacy Network Listing

Find a Medical Provider

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

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    HMO Blue New England (HMO) Participating Primary Care Providers (PCP)

  2. Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care" to begin your search. Or visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    • On the "Find Care" page, in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – NMY – then click the "Search" button.
    • 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 any of the following options:

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    BlueChoice New England (POS) Participating Primary Care Providers (PCP)

  2. Log in to your Secure Enrollee Portal (SEP) account and click on the Anthem button then click "Find Care" to begin your search. Or visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    • 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.
    • Enter your search information.

Prescription Plan Pharmacy Directories

Click on the orange Prescription Plan Pharmacy Directories button below to find a CVS Caremark participating retail pharmacy in New Hampshire. If you are a HealthTrust Enrollee covered by a Lumenos plan, click on the same button to find participating retail pharmacies in New Hampshire.

CVS Caremark - NH Participating Pharmacies*
(*This PDF is updated quarterly; to access CVS Caremark's national pharmacy directory, visit their website and log in as a registered user.)

Anthem NH Retail Pharmacy Network Listing

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 [464 Kb]
Election Worksheet [59 Kb]
Enrollee FSA Brochure [1.36 Mb]
FSA Claim Form [101 Kb]
Healthcare Eligible Expenses List [80 Kb]
Physician Statement [317 Kb]
Void & Reissue Form [98 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, Long-Term Disability and/or Short-Term Disability Application and Change Form* [109 Kb]

Medical and Dental Enrollment

Annuity Deduction Authorization for Medical and Dental Benefits [455 Kb]
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]
Dental Application and Change Form* [417 Kb]
Information Update/Correction Form [152 Kb]
Medical and/or Dental Application and Change Fillable Form* [351 Kb]
Medical and/or Dental Application and Change Form* [210 Kb]
Notice of Divorce, Legal Separation or Dissolution of Civil Union [99 Kb]
Notice of Membership Changes Fillable Form [123 Kb]
Retiree Medical and/or Dental Application and Change Fillable Form* [159 Kb]
Retiree Medical and/or Dental Application and Change Form* [81 Kb]

Medicare Supplemental Plan (Medicomp Three)

Medicomp Three brochure [133 Kb]
Medicomp Three without Prescription Drug Coverage (MCNRX) Election Form [27 Kb]
Retiree ACH Authorization Form [289 Kb]
Retiree Medical and/or Dental Application and Change Form* [81 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

2021 Biometric Health Screening Form - ConvenientMD [167 Kb]
2021 Biometric Health Screening Form - PCP [49 Kb]

Wellness Coordinator Forms and Resources

2022 Wellness Coordinator Academy Application [106 Kb]