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  • Hipaa Designated Contact Form - Anthem

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Ed health information (PHI). Notes: This form must be completed by someone with proper authority within your organization (for example, the Privacy Officer). We require names, not merely job titles, of individuals who may receive PHI. Please complete a new form whenever there is a change to the Designated Contact Person list. ADDITION of contact person CHANGE / DELETION of contact person (please indicate next to name) Producer/Broker Contacts (see below) Check this box if your g.

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Contact support

TPA stands for Third Party Administrator and as such is defined as an organization or individual that handles the claims, processing, and reporting components of a self-funded health benefits plan.

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.

You or your provider can request an expedited appeal. Call Member Services toll-free at 844-912-0938 (TTY 711), Monday through Friday from 8 a.m. to 7 p.m. Eastern time. When we receive your call, we will call you within 72 hours to tell you our decision.

How to find your 1095-A online Log in to your HealthCare.gov account. Under "Your Existing Applications," select your 2022 application — not your 2023 application. Select “Tax Forms” from the menu on the left. Download all 1095-As shown on the screen.

In California Anthem Blue Cross is the trade name of Blue Cross of California.

If you have questions about this form or need additional assistance, contact Provider Services at (844) 396-2330 or contact your local Provider Experience Consultant.

Blue Cross Blue Shield is part of the Anthem family of brands. While the two brands are related, they sell different Medicare plans in different areas.

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

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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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:
1-877-389-0141
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