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Anthem Blue Cross Blue Shield Health Insurance  
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Guest Membership
 

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

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

Important Note: This form should only be completed within 30 days of the date you need Guest Membership to be effective. We cannot process a Guest Membership application with an effective date greater than one month from the date you submit this form.

Required Field Asterisk Required field.
Part 1: Subscriber Information:
 
    Required Field Asterisk First name   
 
    Required Field Asterisk Last name   
 
    Required Field Asterisk Street   
 
    Required Field Asterisk City   
 
    Required Field Asterisk State   
 
    Required Field Asterisk Zip Code   
 
    Required Field Asterisk Home telephone   
 
    Required Field Asterisk Work telephone   
 
    Required Field Asterisk Social security number   
 
    Required Field Asterisk Sex  Male
Female
 
     Date of birth   
 
    Required Field Asterisk Marital Status  Single
Married
Divorced
Widowed
Separated
Domestic Partner
 
     Group number   
 
    Required Field Asterisk Subscriber ID number   
 
    Required Field Asterisk Employment Status  Active
Retired
 
    Required Field Asterisk Email address   
 
 
Part 2: Guest Information:
 
    Required Field Asterisk Relationship to subscriber  Self
Spouse
Dependent
Domestic Partner
 
    Required Field Asterisk First name   
 
    Required Field Asterisk Last name   
 
    Required Field Asterisk Street address when  away from home   
      College students please provide dorm and room number, or P.O. Box.
 
    Required Field Asterisk City   
 
    Required Field Asterisk County   
 
    Required Field Asterisk State   
      Guest Memberships are not available in Alabama, Alaska, Idaho, Iowa, Kansas, Mississippi, Montana, Nebraska, North Dakota, Oregon, Puerto Rico, South Dakota, Tennessee, Utah, Vermont, West Virginia and Wyoming.
 
    Required Field Asterisk Zip Code   
 
    Required Field Asterisk Telephone number when  away from home   
 
    Required Field Asterisk Social security number   
 
    Required Field Asterisk Sex  Male
Female
 
     Date of birth   
 
    Required Field Asterisk Marital Status  Single
Married
Divorced
Widowed
Separated
Domestic Partner
 
     Name of Primary Care
Physician in new area
(if known) 		  
 
     If Guest Member is under age 18 please supply Guardian Name and Phone Number: 
     Name of Guardian
of Minor Child 		  
     Guardian's Phone Number   
 
    Required Field Asterisk Do you have any other insurance?  Yes
No
 
     If yes: Name of other insurance carrier   
     Other insurance
policy number 		  
 
     Medicare  Yes
No
 
Part 3: Coverage Request:
Note: There is a 20 day waiting period on all Guest Member applications.
 
    Required Field Asterisk Period of Coverage (90-day minimum)   Start*
 End
      * Note: Start date should be 30 days or less from today's date. We cannot process a Guest Membership application with an effective date greater than one month from the date you submit this form.
 
    Required Field Asterisk Type of Request  New Request
Renewal
 
    Required Field Asterisk 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)
 
     Please note any special needs:   
 
Part 4: Away From Home Care Authorization:
 
I hereby certify that all information stated in 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. I hereby authorize my Home HMO and my Host HMO 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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