The use of this form is limited to CMS claim format billers only. We encourage you to review the New Provider Application Form Instructions for more detailed information on the application process. Once all of the New Provider Application Form elements are completed, select the "Submit" button at the bottom of the form to complete the submission. The W-9 and any other required documentation must be submitted separately to:. Email: ProviderEducationCommunication anthem. Note : Do NOT use this form to request demographic or practice changes to existing, contracted providers, instead, proceed directly to the Provider Maintenance Form.
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Submission Failed - Submission Failed. You can make the first payment for your new health plan here. If you don't have it, no problem. You can call Member Service at If you purchased your plan through the Health Insurance Marketplace exchange , please call Member Service at