NPI/Tax ID 3. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. If you're a Blue Cross Blue Shield of Michigan or Blue Care Network member and you have coverage through your employer, use this form to let us know of any changes to your status, like address or name changes. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. 170006 (06/11) Anthem Blue Cross and Blue Shield and its affiliated HMO, HealthKeepers, Inc., are independent licensees of the Blue Cross and Blue Shield Association. Forms and Documents. Notify us of a name change Claim forms Health Services Claim form (ABC 20039) This form is used to submit claims for products or services such as prescription drugs, private or semi-private hospital accommodation, ambulance, psychology services, physiotherapy, chiropractic, wheelchairs, vision care and hearing aids. ... SM1 Mark of Blue Cross and Blue Shield of North Carolina. Box 2260 Complete the form and return it to us within 30 days of the change. To … Or you can download and save the form, to review and sign at a later date. The forms in this online library are updated frequently—check often to ensure you are using the most current versions.Some of these documents are available as PDF files. �%RC� ��y�W,��ӲMR���@[��^3�s����v��i���>���[�g1� t��E��X'\�m�}�tm�������e��,����V���[2�[yx�F����&q�|����9��n���V���,L�&QR���s�]MW�����s{��X%��c�y+�lk �)=|�L��ύF����Yߐ%�i@���4�_��ϛO!V@�������c]���%��i+�N�yA�6� Send your letter to: Blue Cross & Blue Shield of Rhode Island Attn: Claims Department 500 Exchange Street Providence, RI 02903 HMO coverage is offered by Health Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. If you have completed a Demographic Change Form, you can check the status of your application by entering the case number you received in your confirmation email in our Case Status Checker.Examples of information you can change include: 1. Change Form. Change Address / Name: In Section 1, check the “Other Change(s)” box, then complete sections 1, 2 and 10. State and Federal Privacy laws prohibit unauthorized access to Member's private information. We regulate the brand and licenses to all 36 Blue Cross and Blue Shield local companies. BCBSAZ will not be responsible for lost or returned mail if we do not Blue Cross and Blue Shield of Louisiana and its subsidiaries, HMO Louisiana, Inc. and Southern National Life Insurance Company, Inc., comply with applicable federal civil rights laws and do not exclude people or treat them differently on the basis of race, color, national origin, age, disability or sex. Vision change form [pdf] If so, we can help you make the most of your benefits—and possibly save you money! The purpose of this form is to help members of an employer-sponsored insurance plan update us when they have any changes to their status such as: Please contact your employer to see if you need to update your address or policy information with them first before filling out the Change of Status form. Third Party Website Icon: Please be aware when you are on the Blue Cross and Blue Shield of Minnesota (Blue Cross) website and see this Third Party Website icon, you will be connected to a third party site, whether via links provided by Blue Cross or otherwise, and you will be subject to the privacy policies of the third party sites. We apologize for the inconvenience. Enrollment Change Request Form These forms should be used by current Blue Medicare HMO and PPO members to enroll in different Blue Medicare HMO and Blue Medicare PPO plans. Page 1 of 2. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield … Add/Remove Dependent. To review and sign your request now electronically, select the sign now option below. Download Form: Change Notification Form: Complete this form if your name changes through marriage or other event, or if your mailing address changes. Primary Care Provider Selection Form – Blue Cross Community Centennial Members must select a PCP. Application / Change Form Author: Blue Cross NC 08/2019. ® Registered marks of the Blue Cross and Blue Shield Association. Rev. Change Address/Name: Complete Section 1 and check the “Other Change(s)” box; then, complete Sections 2 and 9. Thank you for being a part of the Anthem network of health care professionals! Page 1. Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. 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