Anthem Blue Cross and Blue Shield Miscellaneous Forms

For the convenience of our Clients with Individual Health Insurance policies, the most up to date and commonly used forms can be found below.  For assistance with these forms, please contact your Licensed Benefit Consultant at (636) 229-7000.

1. Change Forms
A. Missouri Downgrade/Policy Change Form
This form can be used to make changes as outlined on the form.  This form cannot be used to: add a spouse, add a dependent (except for a newborn child), upgrade product benefits, make changes to life coverage, or add an optional coverage rider.

B. Missouri Change of Coverage Application
This form can be used for the upgrade of medical benefits or a risk review.  This form cannot be used to add members not currently covered.

2. Medical Questionnaires
A list of Medical Questionnaires can be found below.  To download one of the questionnaires, click on the name of the questionnaire needed and a PDF of the document will be displayed for you to print.  If you have questions regarding the questionnaires, please contact your Licensed Benefit Consultant  at (636) 229-LANG. 

A. Abnormal Pap Smear Questionnaire

B. Alcohol & Drug Questionnaire

C. Arthritis Questionnaire

D. Asthma/Allergy Questionnaire

E. Attention Deficit Disorder Questionnaire

F. Colitis/Irritable Bowel Questionnaire

G. Diabetes Questionnaire

H. Digestive Questionnaire

I. Ear/Otitis Questionnaire

J .Endometriosis Questionnaire

K. Fibromyalgia Questionnaire

L. Gout Questionnaire

M. Heart Murmur/MVP Questionnaire

N. Hypertension Questionnaire

O. Kidney/Urinary Disorder Questionnaire

P. Mental Health Questionnaire

Q. Migraine Questionnaire

R. Seizure/Epilepsy Questionnaire

S. Spinal Questionnaire

T. Thyroid Questionnaire

U. Tumor/Cyst/Skin Cancer Questionnaire

V. Ulcer Questionnaire

 
In Missouri (excluding 30 counties in the Kansas City area): Anthem Blue Cross and Blue Shield is the trade name for RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the blue Cross and Blue Shield Association.