Get 1 Affiliate Means Any Entity That Owns Or Is Owned By Anthem, Directly Or Indirectly, And Any

Filling out the 1 Affiliate Means Any Entity That Owns Or Is Owned By Anthem application can seem overwhelming. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently, ensuring you meet all requirements.

Follow the steps to complete the affiliate form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Enter the Provider Corporate Entity Name. This should be the legal name of the provider or owner of the tax identification number(s). Make sure to write it clearly and accurately.
3. Fill in the address details including the street, suite, city, state, and zip code. Ensure that this information is accurate to avoid any processing delays.
4. List the tax identification numbers. If there are multiple tax IDs, provide them clearly and separately, attaching an additional list if necessary.
5. Designate the Site Administrator responsible for managing access for operators. Include their name, title, email address, and contact information.
6. In the Operator Listing section, provide the name, title, and email addresses of each operator. Specify whether they are an Operator (OP) or Designated Agent (DA).
7. Indicate the access required for each operator by checking the relevant boxes (such as Reports or Fee Schedule). This will help ensure each operator has the necessary permissions.
8. Review all the entered information for accuracy. Make necessary corrections to avoid any issues during processing.
9. Sign and date the form at the designated areas to confirm the accuracy of the information provided and your authority to submit the form.
10. Once you have completed the form, choose to save the changes, download, print, or share the form according to your needs.

Complete your documents online today for a seamless experience.