Forms

Below are links to forms related to WELS VEBA:

• Anthem BCBS 2008-2010 Claim Form
  (For claims incurred in the United States with dates of service on or after January 1, 2008. Please contact Anthem at 1-877-512-7875 for the address of your local Blues plan)



• Anthem BCBS 2008-2010 Vision and Flu Shot Member-Submitted Claim Form
  (Use this form only if your provider will not submit vision or flu shot claims to Anthem on your behalf. For claims incurred with dates of service on or after January 1, 2008.)



• Blue Cross Blue Shield 2005-2007 U.S. Claim Form
  (For claims incurred in the United States with dates of service beginning January 1, 2005 through December 31, 2007. Please contact the BPO for the address of your local Blues plan.)



• Blue Cross Blue Shield Worldwide Claim Form
  (For claims incurred outside the United States with dates of service on or after January 1, 2005. Send claims to the Benefit Plans Office at the address below.)



• Medco Prescription Drug Reimbursement Form
• Medco Prescription Drug Mail Service Form



• Student Status Form
• Coordination of Benefits (COB) Form
• Newborn Report Form
• Anthem BCBS Health Information Release Form
• WELS VEBA Health Information Release Form

These forms are also available from the Benefit Plans Office and will be mailed upon your request.

Upon completion, please mail all forms (with the exception of the BCBS U.S. claim forms, BCBS vision claim form, prescription drug forms, and the Anthem health information release form) to the Benefit Plans Office at the following address:

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