This health insurance enrollment form is used by individuals and families to apply for or change their plan through Anthem. Anthem uses the details you provide to determine eligibility, assign a plan, and calculate your premium rate. The form is 28 pages long and must be completed in full.
Who needs this form? You need this PDF if you want to:
What details are required? The form asks for personal data from every applicant: full legal name, date of birth, gender, Social Security ID, and contact details. You must also provide your marital status, language preference, and home address. For each dependent, the same personal data is required.
Plan selection. Choose from available Anthem plan types by region: HMO (requires referrals), PPO (allows direct specialist access), or a combined medical and dental plan. If you select dental, note whether a waiting period applies before dental benefits begin. Your subscriber ID from any current Anthem policy must be included to match your records.
Prior insurance history. Anthem requires data about your previous health plan, including the carrier name and your policy dates. You must also indicate whether any applicant is currently enrolled in Medicare or Medicaid and provide their member identifier. This determines whether creditable coverage applies and affects any waiting periods for benefits.
Effective date and payment. Enter your requested start date for new health benefits. Anthem reviews and approves start dates based on submission timing and plan availability. The approved date may differ from your request. Your first premium payment must accompany the completed form. Benefits do not begin until Anthem processes both the enrollment document and your payment.
Related forms on FormsPal: Capital Blue Cross Provider Appeal Form and Regence Blue Cross Authorization Request.
| Question | Answer |
|---|---|
| Form Name | Anthem Blue Cross Application Form |
| Form Length | 28 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 7 min |
| Other names | anthem information applicant, anthem cross applicant, anthem application applicant get, anthem application applicant online |