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 |
| Dental Claim (All states except NY) | Use this form to report a treatment plan and to initiate a dental claim. |
Download |
| Dental Claim (NY) | Use this form to report a treatment plan and to initiate a dental claim. For use in New York only. |
Download |
| Dental Claim (Spanish - All states except NY) | Use this form to report a treatment plan and to initiate a dental claim (Spanish). |
Download |
| Dental Claim (Spanish - NY) | Use this form to report a treatment plan and to initiate a dental claim (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 |
| Pregnancy Dental Benefit Certification (All states except NY) | Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. |
Download |
| Pregnancy Dental Benefit Certification (NY only) | Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. For use in New York only. |
Download |
| Pregnancy Dental Benefit Certification (Spanish - All states except NY) | Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. (Spanish) |
Download |
| Pregnancy Dental Benefit Certification (Spanish - NY only) | Authorize the release of medical information to The Standard for review for the Maternity Dental Benefit. (Spanish) For use in New York only. |
Download |