Forms

HEALTH BENEFITS
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Medical Claim Form

(Claims after 01/01/21)

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Medical Claim Form

(Claims before 01/01/21)
 

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)

Reimbursement Request Form
 

Breast Pump

Breast Pump Info & Order Form

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Prescription Claim Form

Complete the claim form and submit it to:

ProAct Inc.

1230 US HWY 11

Gouverneur, NY 13642

Attn: DMR Dept.

ProAct Letter of Medical Necessity

Mail Order Form

Costco Mail Order Pharmacy

215 Deininger Circle

Corona, CA  92880-9911

PROPERTY/CASUALTY
MEMBERS

JPA Delegate Forms

Designation of Delegate
 

Form 700