Anthem Blue Cross Blue Shield Health Insurance  
Care Management Referral Form

If one of our members has needs that require immediate intervention by a case manager, please call 1-800-231-8254, or fax to 1-800-447-5523, or email


 Required field.

1. Patient's Name
  Last Name:  
  First Name:  
2. Certificate Number/Anthem ID Number:
3. Date of Birth (MM/DD/YYYY):
  Month:  Day:  Year:
4. Address
  Street 1:  
  Street 2:  
  Zip Code:  
5. Home Phone Number:
 Area Code: (  )  Phone:  -
6. Work Phone Number:
 Area Code: (  )  Phone:  - Ext: 
7. Good Time to Call:
8. Physician Name:
9. Have you discussed case management with your patient?
   Yes No
10. Health Status/Reason for Notification:




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