Forms

For reimbursement complete items 1-11 of the claim form, attach receipt(s) and submit to:

FOR CLAIMS IN CALIFORNIA

Anthem Blue Cross of California

PO Box 60007

Los Angeles, CA 90060-0007

FOR CLAIMS OUTSIDE
OF CALIFORNIA

Anthem Blue Cross/Blue Shield of the state the medical services were performed. If you have questions, call 800-810-BLUE(2583).

If you need the provider reimbursed then also sign item 12 and following the same procedures listed above. One claim form per patient.

PhysMetrics
(formerly ChiroMetrics)

Breast Pump

Prescription Claim Form

Complete the claim form and submit it to:

Claims Department
P.O. Box 52065
Phoenix, AZ 85072-2065

Or fax to Fax: 401-404-6344

** Please include copies of the receipts**

Delegate Forms