Get Anthem Member Deletion Form

Filling out the Anthem Member Deletion Form is a straightforward process that allows primary medical providers to request the disenrollment of a member from their care assignment. This guide will provide you with clear and detailed instructions to complete the form online effectively.

Follow the steps to complete the Anthem Member Deletion Form.

1. Click the ‘Get Form’ button to access the Anthem Member Deletion Form and open it in your preferred online editor.
2. Begin by filling out the ‘Provider Information’ section. Enter the name of the primary medical provider (PMP) and their contact phone number.
3. Next, complete the ‘Member Information’ section. This includes the member's name, member ID number, date of birth, and phone number.
4. Move on to the ‘Reason for Request’ section. Indicate the basis for your request, such as excessive missed appointments or disruptive behavior. Be specific in the circumstances section provided.
5. If applicable, answer the questions regarding whether you have seen the member and the specific circumstances of the request. Use the notes section for any additional comments.
6. After completing all sections, review the information for accuracy. Once confirmed, you can save your changes, download the completed form, or share it as necessary.

Take action today and fill out your Anthem Member Deletion Form online to ensure a smooth processing experience.