Forms

Health Benefits

Medical Claim Form

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
Prescription Claim Form
Carelon Rx

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**

BOARD MEMBERS

Delegate Forms