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  • Ca Anthem Blue Cross Disabled Dependent Certification

Get Ca Anthem Blue Cross Disabled Dependent Certification

1. Subscriber s Name (Last, First, Middle Initial) 1a. Identification Number 2. Home Address (Number, Street, City, State and Zip Code) 3. Group Name 3a. Group Number 4. Dependent s Name 4a. Dependent s Birth Date 5. Does the Dependent reside in your 6. Is he more then 50% dependent upon Home? Yes No 8. Is dependent employed? you for support? Yes 4b. Dependent s Marital Status 7. Is he listed as dependent in your last Federal Income Tax No Return? 8a. Date.

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In most other states, they are the same company and formed an association, the Blue Cross Blue Shield Association. Anthem Blue Cross is a for profit company in California, and Blue Shield is a non-profit.

In California Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.

What do I include with my appeal? If your appeal is about a Part D drug: Your completed Redetermination Request Form. Your name, address and member ID number. Your reasons for appealing. Any information or evidence (documents, medical records) to support your appeal.

By Phone: Call the number on the back of the member's ID card or dial 800-676-BLUE (2583) to speak to a Provider Service representative.

Phone: (800) 541-6652, TTY 711, Monday – Friday, 8 a.m. – 5 p.m. Call for questions about: Member eligibility.

In Central California counties, please email CentralProviderRelationsMedicaid@anthem.com or call 1‑877‑811‑3113.

Care Management support is available 24/7 through Anthem Blue Cross Cal MediConnect Plan Customer Care at 1-855-817-5786.

The appeal must be received by Anthem Blue Cross (Anthem) within 365 days from the date on the notice of the letter advising of the action.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232