Forms

HIPAA Privacy

• Authorization to Release Protected Health Information
• Request for Restriction on Use and Disclosure of Health Care Information and/or Confidential Communication
• Member Record Amendment/Correction

Subscriber Forms

• Automatic Withdrawal Authorization
• Notice of Special Enrollment Rights

Public Entity Forms

• Automatic Withdrawal Authorization

Medical Plan

• Anthem Medical Claim Form
• Anthem International Claim Form

Prescription Drug Plan

• ESI Claim Form

Dental and Vision Plans

• MetLife Dental Claim Form
• MetLife Preventive Plus Program Form
• NVA Claim Form