Common Forms
This page includes only standard versions of our most-used forms. Many forms are specific to your policy or plan and aren't listed here. If you don't see what you need, please contact us or your benefits administrator.
Former Anthem Life customers should log in to get their claim forms.
| Title | Purpose | Action |
|---|---|---|
| ACH for Dental & Vision Customers Based in NY | Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House. For use in New York only. |
Download |
| ACH for Dental & Vision Customers Based Outside NY | Use this form to request and authorize an agreement for prearranged payments via Automated Clearing House. |
Download |
| Authorization to Release Health-Related Information | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. |
Download |
| Authorization to Release Health-Related Information (NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. For use in New York only. |
Download |
| Authorization to Release Health-Related Information (Spanish - All states except NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. (Spanish) |
Download |
| Authorization to Release Health-Related Information (Spanish - NY) | Authorize The Standard to release dental and/or vision insurance information to a designated recipient. (Spanish) For use in New York only. |
Download |
| EFT for Dental & Vision Customers Based in NY | Use this Electronic Funds Transfer form to request and authorize a bank payment plan. For use in New York only. |
Download |
| EFT for Dental & Vision Customers Based Outside NY | Use this Electronic Funds Transfer form to request and authorize a bank payment plan. |
Download |
| Eye Med Vision Out of Network Claim | Used to initiate an out of network eye care claim. |
Download |
| Vision Claim Form (All states except NY) | Use this form to initiate a vision or PolicyLink claim. |
Download |
| Vision Claim Form (NY) | Use this form to initiate a vision or PolicyLink claim. For use in New York only. |
Download |
| Vision Claim Form (Spanish - All states except NY) | Use this form to initiate a vision or PolicyLink claim (Spanish). |
Download |
| Vision Claim Form (Spanish - NY) | Use this form to initiate a vision or PolicyLink claim (Spanish). For use in New York only. |
Download |
| VSP Vision Out of Network Claim | Used to request out of network eye care expense reimbursement. |
Download |