Forms and Documents

Forms, Documents, and Brochures

The following forms and resources are saved as PDFs and available to download. Listings marked with an asterisk (*) indicate they are normally carbonless, multi-part forms but cannot be provided as such electronically. Please check the bottom of each of those forms’ pages for a notation regarding their usual color-coded sections and make an appropriate number of copies to distribute accordingly once completed. For access to additional forms, please log in to the secure web portal.

Medical Plan Provider Directories

To find a Primary Care Provider (PCP) or other medical provider, or to view a list of Anthem walk-in centers, urgent care centers and CVS Minute Clinics, click on the link with your plan name, below.

Find a Medical Provider

To find a PCP or another type of provider in NH or other New England states, choose any of the following options:

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    Anthem Access Blue New England (HMO) Participating Primary Care Provider (PCP) List

  2. Visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the Find a Doctor page, under "Search as Member," in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – EHH – for your Access Blue New England (HMO) plan, then click the "Continue" button.
    2. On the next page, enter the information required to complete your provider search; then click on the "Search" button.
  3. Click on the state link below to access that state's Anthem website and/or provider directory:

Find a Medical Provider

To find a PCP or another type of provider in NH or other bordering New England states, choose any of the following options:

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    Anthem Access Blue New England (HMO) Participating Primary Care Provider (PCP) List

  2. Visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the Find a Doctor page, under "Search as Member," in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – YGC – for your Access Blue New England (HMO) plan, then click the "Continue" button.
    2. On the next page, enter the information required to complete your provider search; then click on the "Search" button.

Find a Medical Provider

To find a PCP or another type of provider in NH or other New England states, choose any of the following options:

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    Anthem Access Blue New England Site of Service (HMO) Participating Primary Care Provider (PCP) List

  2. Visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the Find a Doctor page, under "Search as Member," in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – EHH – for your Access Blue New England (HMO) plan, then click the "Continue" button.
    2. On the next page, enter the information required to complete your provider search; then click on the "Search" button.
  3. Click on the state link below to access that state's Anthem website and/or provider directory:

Find a Medical Provider

To find a PCP or another type of provider:

Visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

  1. On the Find a Doctor page, under "Search as Member," in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – YGF – for your Access Blue New England (HMO) plan, then click the "Continue" button.
  2. On the next page, enter the information required to complete your provider search; then click on the "Search" button.

Find a Medical Provider

To find a PCP or another type of provider in NH or other New England states, choose any of the following options:

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    HMO Blue New England (HMO) Participating Primary Care Providers (PCP)

  2. Visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the Find a Doctor page, under "Search as Member," in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – NHN – for your Access Blue New England (HMO) plan, then click the "Continue" button.
    2. On the next page, enter the information required to complete your provider search; then click on the "Search" button.
  3. Click on the state link below to access that state's Anthem website and/or provider directory:

Find a Medical Provider

To find a PCP or another type of provider in NH or other New England states, choose any of the following options:

  1. Simply click on the following link to access a list of PCPs who participate with Anthem BCBS in New Hampshire.

    BlueChoice New England (POS) Participating Primary Care Providers (PCP)

  2. Visit the Anthem Blue Cross and Blue Shield Website Provider Directory and follow the instructions below:

    1. On the Find a Doctor page, under "Search as Member," in the Identification number or alpha prefix (first three letters) field, enter the alpha prefix – NHP – for your Access Blue New England (HMO) plan, then click the "Continue" button.
    2. On the next page, enter the information required to complete your provider search; then click on the "Search" button.
  3. Click on the state link below to access that state's Anthem website and/or provider directory:

Prescription Plan Pharmacy Directories

Click on the orange Prescription Plan Provider Directories button below to find a CVS Caremark participating retail pharmacy in New Hampshire. If you are a HealthTrust Enrollee covered by a Lumenos plan, click on the same button to find participating retail pharmacies in New Hampshire.

CVS Caremark - NH Participating Pharmacies*
(*This PDF is updated quarterly; to access CVS Caremark's national pharmacy directory, visit their website and log in as a registered user.)

Express Scripts
(To search for participating providers and to check the status of prescriptions, please log in as a registered user.)

Dental Plan Provider Directories

To find a participating dentist in New Hampshire, click on the Dental Plan Provider Directories button below.

Northeast Delta Dental Directory
(Select "Delta Dental Premier" for plan type)

Benefit Advantage FSA/HRA Services

Change in Status form [350 Kb]
Direct Deposit Authorization Form [121 Kb]
Election Worksheet [59 Kb]
Flex Claim Form [101 Kb]
Healthcare Eligible Expenses List [107 Kb]
Physician Statement [317 Kb]
Void & Reissue Form [98 Kb]

Claims

Anthem Subscriber Claim Form [46 Kb]
CVS/caremark Prescription Reimbursement Claim Form [171 Kb]
HealthTrust Incentive Program Reimbursement Request Form [376 Kb]
Northeast Delta Dental Claim Form [747 Kb]

CVS/caremark Prescription Drug Program

CVS/caremark Mail Service Order Form [318 Kb]
CVS/caremark Prescription Reimbursement Claim Form [171 Kb]

Life, Long-Term Disability and Short-Term Disability Enrollment

Life, Long-Term Disability and/or Short-Term Disability Application and Change Form* [109 Kb]

LifeResources

LifeResources Employee Assistance Program Brochure [2.13 Mb]

Medical and Dental Enrollment

Annuity Deduction Authorization for Medical and Dental Benefits [455 Kb]
Certificate of Tax Dependent Status for a Civil Union Partner* [126 Kb]
Certification for a Mentally or Physically Disabled Dependent Child Over Maximum Age [121 Kb]
Dental Application and Change Form* [417 Kb]
Information Update/Correction Form [152 Kb]
Medical and/or Dental Application and Change Form* [210 Kb]
Notice of Divorce, Legal Separation or Dissolution of Civil Union [99 Kb]
Retiree Medical and/or Dental Application and Change Form* [81 Kb]

Medicare Supplemental Plan (Medicomp Three)

Medicomp Three brochure [133 Kb]
Medicomp Three without Prescription Drug Coverage (MCNRX) Election Form [27 Kb]
Retiree Medical and/or Dental Application and Change Form* [81 Kb]

Privacy and Security (HIPAA)

HIPAA Authorization to Release Information [35 Kb]
Notice of Privacy Practices [170 Kb]
Request for Accounting of Disclosures [33 Kb]
Request for Confidential Communications [27 Kb]
Request for Restriction on Uses and Disclosures [33 Kb]
Request to Amend a Record [33 Kb]
Request to Inspect Health Information [34 Kb]
Revocation of Authorization to Release Information [29 Kb]
Termination of Restriction on Use and Disclosures [28 Kb]

Slice of Life

2018 Biometric Health Screening Authorization Form - ConvenientMD [222 Kb]
Annual Physical and Preventive MD Visit Form (For Medicomp-Covered Enrollees Only) [106 Kb]
Biometric Health Screening Form 2017 [670 Kb]
Health Awareness Program Reimbursement Request Form 2017 [2.2 Mb]
Wellness Coordinator Academy Application [93 Kb]

Wellness Coordinator Forms and Resources

Wellness Coordinator Academy Application [93 Kb]