Anthem Blue Cross Blue Shield Health Insurance  
Connecticut SIU Referral Form


1. Member, Provider, or Health Care Facility Information:

First Name:
Last Name:
Street 1:
Street 2:
Zip Code:
Phone Number: ()   - Ext: 
Patient First Name:
Patient Last Name:
Member Number:
Provider Name:
Claim Number:

2. Suspected Illegal or Wrongful Billing Practices:

3. Submitter's Information (Leave blank for anonymous referrals):

First Name:
Last Name:
Phone Number: ()   - Ext: 




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