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Get and Sign Anthem Authorization Form 2018-2022
Mm/dd/yyyy.
(If you were born on October 5, 1960, you would
write 10/05/1960.)
3 Write your full street address, city, state, and ZIP code.
4 Write your daytime phone number (including area code.)
5 Write your cell/mobile number (including area code).
6 Identification number
You will find this number on your member
identification card.
7 Group number
You will find this number on your member identification
card. If your identification card does not have a group
number leave this blank.
Part B:...
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