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Get Anthem Member Authorization Form 2018-2024

E following for help completing page one of the form. Part A: Member information This section applies to the member who is asking for the release of his or her information to another person or company. 1 Print your last name, first name, and middle initial. 2 Write your date of birth in this format: 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.

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