Forms and Documents

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.

Access Blue New England (HMO)
BlueChoice New England
HMO Blue New England

Find a PCP or another type of provider (specialists, hospitals, labs, behavioral health providers, and more):

Anthem Access Blue New England (HMO) Participating Primary Care Provider (PCP) List – this list includes PCPs who participate with Anthem BCBS in New Hampshire.

To search for participating PCPs or other providers in other New England states, follow the directions in either option 1 or 2:

  1. Visit Anthem Blue Cross and Blue Shield Website Provider Directory
    1. On the Find a Doctor page, under "Search as Member," in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix "EHH" for Access Blue New England, "NHP" for BlueChoice New England, or "NHN" for HMO Blue New England; then click the "Continue" button.
    2. On the next page, enter the information required to complete your provider search; then click on the Search button.
  2. Click on the state link below to access that state’s website provider directory:

Access Blue New England Site of Service Plans: To find Site of Service preferred Lab or Ambulatory Surgery Centers, visit anthem.com/siteofservicenh or call the Anthem Customer Service number located on the back of your Anthem ID card.

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.)

Express Scripts
(To search for participating providers and to check the status of prescriptions, please log in as a registered user.)

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

Claims

Anthem Subscriber Claim Form [46 Kb]
CVS/caremark Prescription Reimbursement Claim Form [171 Kb]
HealthTrust Incentive Program Reimbursement Request Form [376 Kb]
Northeast Delta Dental Claim Form [747 Kb]

CVS/caremark Prescription Drug Program

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

Flexible Spending Account (FSA)

Dependent Care Reimbursement Account Brochure [205 Kb]
Flexible Benefits Plan Change-in-Status Form [157 Kb]
FSA Direct Deposit Authorization Form [156 Kb]
FSA Frequently Asked Questions - Benny Card Flyer [97 Kb]
FSA Prepaid Benefits Card - Save Your Receipts Flyer [137 Kb]
FSA Prepaid Benefits Card Brochure [324 Kb]
Healthcare FSA Brochure [213 Kb]
Healthcare FSA List of Eligible/Ineligible Expenses [46 Kb]
Healthcare FSA/Dependent Care Reimbursement Account Reimbursement Form [166 Kb]
Physician’s Statement of Medical Necessity [129 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]

LifeResources

LifeResources Employee Assistance Program Brochure [2.13 Mb]

Medical and Dental Enrollment

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

Privacy and Security (HIPAA)

Authorization to Release Information [34 Kb]
Notice of Privacy Practices [170 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

Annual Physical and Preventive MD Visit Form (For Medicomp-Covered Enrollees Only) [106 Kb]
Biometric Health Screening Form 2017 [670 Kb]
Health Awareness Program Reimbursement Request Form 2017 [2.2 Mb]
Wellness Coordinator Academy Application [93 Kb]

Wellness Coordinator Forms and Resources

Wellness Coordinator Academy Application [93 Kb]