Anthem Blue Cross Health Insurance  

Please complete a separate application for each family member who will be residing outside of your state.

(Note: There are 21 states that do not participate in this program: Alabama, Alaska, Idaho, Iowa, Kansas, Michigan, Mississippi, Montana, Nebraska, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, Utah, Virgin Islands, Washington, Wyoming, West Virginia, and Puerto Rico.)

 Required field.
Part 1: Subscriber Information:
 
     First name 
 
     Last name 
 
     Street 
 
     City 
 
     State   (Note: Guest Memberships are not available in Alabama, Alaska, Idaho, Iowa, Kansas, Michigan, Mississippi, Montana, Nebraska, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, Utah, Washington, Wyoming, West Virginia, and Puerto Rico.)
 
     Zip Code 
 
     Home telephone 
 
     Work telephone 
 
     Social security number 
 
     Sex  Male
Female
 
     Date of birth 
 
     Marital Status  Single
Married
Divorced
Widowed
Separated
Domestic Partner
 
     Group number 
 
     Subscriber ID number 
 
     Employment Status  Active
Retired
 
     Email address 
 
 
Part 2: Guest Information:
 
     Relationship to subscriber  Self
Spouse
Dependent
Domestic Partner
 
     First name 
 
     Last name 
 
     Street address when  away from home  (Note: College students please provide dorm and room number, or P.O. Box.)
 
     City 
 
     County 
 
     State   (Note: Guest Memberships are not available in Alabama, Alaska, Idaho, Iowa, Kansas, Michigan, Mississippi, Montana, Nebraska, North Carolina, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Tennessee, Vermont, Utah, Washington, Wyoming, West Virginia, and Puerto Rico.)
 
     Zip Code 
 
     Telephone number when  away from home 
 
     Social security number 
 
     Sex  Male
Female
 
     Date of birth 
 
     Marital Status  Single
Married
Divorced
Widowed
Separated
Domestic Partner
 
     Name of Primary Care
Physician in new area
(if known) 
 
     Medicare  Yes
No
 
Part 3: Coverage Request:
 
     Period of Coverage (90-day minimum)  Start
End
 
     Type of Request  New Request
Renewal
 
     Type of guest service  Families apart (Spouse or dependent that does not reside in your state for 90 days or more)
Student (Dependent of subscriber that does not reside in your state for 90 days or more)
Long-term traveler (Subscriber, spouse or dependent that does not reside in your state for 90 to 180 days)
 
Part 4: Sign off for AFHC Guest Application:
 
I hereby certify that all information stated in Sections A and B on the front of this application is truthful and correct to the best of my knowledge. I acknowledge that the benefit program providing coverage to myself or eligible dependents as Guest Members of the Host HMO may vary from the benefit program at my Home HMO. I understand that as a Guest Member the Host HMO benefit program's scope and levels of coverage apply. (This does not apply to GM, members receiving home benefits).

I hereby authorize my Home HMO and the Host HMO, identified on the front of this application, to exchange medical information about me.

 
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Anthem Blue Cross and Blue Shield

is the trade name for the following: In Connecticut: Anthem Health Plans, Inc. In Colorado, Rocky Mountain Hospital and Medical Service, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky. In Maine: Anthem Health Plans of Maine, Inc. In Missouri: RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC) and HMO Missouri, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi) and Compcare Health Services Insurance Corporation (Compcare). Independent licensees of the Blue Cross and Blue Shield Association. Serving residents and businesses in Indiana, Kentucky, Missouri, Ohio, Wisconsin, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web sites constitutes your agreement with our Terms of Use.

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