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As.NTHEM BLiTE CR??S AND Bi.UE SMELD
<br />J PROVIDEI2MAYNT'ENANCE FORM
<br />Anthem.41.9.
<br />Rehmmiiab the Prov'sder Mainteiaance Fvrm ta Authem
<br />°-thmit tae farrm to the An#.hem losatian Iistes3 in the ieft eolamn of the county wrlnere you practiee.
<br />-nd by mail or fax Attent'son:1'rovider RPlatioas
<br />Anthem Blue Cross and Blue Shield NorthwesY Indiana Couaties:
<br />1000 E 80'h Place, Suite 500 Fulton, Jasper, Lake, La Porte, Marshall, Newton, Porter, Pulasici, St. Joseph, Starke,
<br />Merrillville, IN 46410
<br />FAX #: (219)796-9522
<br />Anthem Blue Cross and Blue Shield
<br />9921 Dupont Circle, West Ste LO Northeast Indiana Counties:
<br />Adams, Allen, Blackforf, DeKalb, Elkhart, Grant, Huntingtoa, Jay, Kosciusko, LaGrange, Miami, Noble, Steuben, Wabash,
<br />Fort Wayne, IN 46825 Wells, WIufley
<br />FAX #: (260) 399-7281
<br />Anthem Blue Cross and Blue Shield
<br />PO BOX 7101 Central Yndiama Counties:
<br />Brown, Carroll, Cass, Clinton, Decatur, Delawaze, Fayette, Hamilton, Haucock, Hendricks,
<br />Boone
<br />Beaton
<br />Bartholomew
<br />IN 46207-7101
<br />Indianapolis ,
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<br />Henry, Howard, Jackson, Jennings, Johnson, I.awrence, Madison, Marion, Moaroe, Montgomery, Morr, Owen, Pazke,
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<br />FAX (317) 287-8906 Putnam, Randolph, Rush, Shelby, Tippecanoe, Tipton, Vermillion, Wazren, Wayne, White
<br />Anthem Blue Cross and Blue Shield
<br />7501 Eagle Crest Blvd. Southem Indiana Counties:
<br />1NDIANA: Clay, Daviess, Dubois, Gibson, Greene, Knox, Martin, Perry, Pike, Posey, Spenca, Sullivan, Vanderburoh,
<br />Evansville, IN 47715 Warrick, Vigo
<br />FAX #: (812) 469-7537
<br />Anthem Biue Cross and Blue Shield SoutfiwesYern Ohio / NortheasYern Kentucky/SoutheasLern Indiana Counties:
<br />Clinton, Gallia,Hamiiton, Highland, Jackson, Lawrence, Meigs, Pike,
<br />Clermont
<br />Sufler
<br />Brown
<br />Atheas
<br />Adams
<br />OHIO
<br />4361 Irwin Simpson Rd. ,
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<br />Mason, OH 45040 Ross,Scioto, Viaton, Wazren.
<br />FAX # (513)770-7510 KEi1ITUCKY: Boone, Campbell, Crallatin, Grant, Kenton, Pendleton
<br /> INDIANA: Dearbom, Franklin, Ohio, Ripley, Switzerland, Union
<br /> West Virgina• Jackson Mason
<br />Anthem Blue Cross and Blue Shield Kentucky (escept Northeastern) /South Central Indiana Counties:
<br />SOYIe, Bracken, Breathitt, Breclan[idae, Bullitt,
<br />Bourbon
<br />B°Yd
<br />Bath
<br />Bell
<br />Basen
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<br />13 550 Triton Pazk Blvd
<br />KY 40223
<br />Louisville .
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<br />erson,
<br />KENT[JCKY: Adair, AIlen, An
<br />CaldweIl, Calloway, Cazlisle, Cazroll, Carter, Casey, Chrishan, C1ar1S Clay, Clmton, Crittenden, Cimmbaland, Daviess, Edmonson,
<br />Butla
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<br />FAX ": (502) 889-2733 ,
<br />Elliott, Estill, Fayette, Flemnm?, Floyd, Franklm, Fukon, Craa-acd, Graves, GraYson, Green, CreerruP, Hancock, Hardin, Haz3an, Hacrison,
<br />La-1, Iawcence, Lee, Leslie,
<br />Lazue
<br />Knwc
<br />Knott
<br />Johnson
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<br />Hart, Hendasan, Henry, Hiclnian, Hopidns, Jackson, Jeffersoq
<br />Livingson, Losan, LYon, Madison, Maggoffm, Mazion, Muhlenber°, Mazshall, Maitin, Mason, McCmcken,
<br />L.mco3n
<br />Lewis
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<br />Meade, Menifee, Metcalfe, Maeer, Montgomay, MoIodII, Mo-, NeLson, Nicholas, Ohio, Okham, Oweq Owsley,
<br />McLean
<br />McCreazy
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<br />Pary, Pike, Powell, Pulaski, Robeitsoa, Rockcastle, Rowan, Russell, Scott, Sheiby, Simpsoa, Spenca, Taylor, Todd, Trig_g Trimble,
<br /> Union, Wazren, Washino on, Wayne, Webster, Wbitley, Wolfe, Woodford
<br /> IN-DIANA: Clazk, Crawford, Floyd, Hazrison, Jefferson, Orange, Scott, Washina on
<br /> T?INFSSEE: CaaxpbeIl, Claubeme, C1aY, HemY? Lake, Mac;an, MontgomaY, Obian, Pickett, Robatson, Seott, Stewart? Sttmna, Weakley
<br /> VIRGU,iIA: Buchanan, Dickenson, Lee, iNorton, Wise
<br /> WEST VIftGINIA: Cabell, Mingo, Wayne
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<br />Anthem Blue Cross and Blue Shield AlQ'on /Canton Ohio CounQes:
<br />4150 Belden Village St Ir'W Carroll, Holmes, Medina, Portage, Stark, Summit, Tuscarawas, Wayne
<br />Canton, OH 44718-2565
<br />FAX #: (330) 493-2148
<br />?,nthem Blue Cross and Blue Shield Cieveland Ohio Counffies:
<br />8333 Rockside Rd #200 OHIO: Ashtabula, Cuyahoga, Geau;a, Lake, Lorain
<br />Cleveland, OH 44125 pENNSYLVADIIA: Crawford, Erie
<br />FAX #: (216) 573-4615
<br />Anthem Blue Cross and Blue Shield
<br />6740 North High Sz Central Oh io Couaties:
<br />Ashland, Coshocton, Crawford, Delawaze, Fairfieid, Franklin, Guemsey, Hockin„ Knox, Lickin„ A/Iadison, Marion„ Monroe,
<br />Worthina on, OH 43085-7500 Morgan, Maskingum, Noble, Perry, Pickaway, Richland, Ilnion, Washinaton
<br />FAX #: (614) 438-3900 WEST VIRGINIA: Pleasant, Tyler, Wetzel, Wood
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<br />Anthem Blue Cross and Blue Shield
<br />1222 South Patterson Blvd, 4th Flr. WesYern Ohio Counties:
<br />Allen, Auglazie, Butler, Champaign, Clark, Clinton, Darke, Defiance,Fayette, Fulton, Greene, Hancock, hardin, Henry, Logan,
<br />Dayton, OH 45402 Mercer, Miami, Montgomery, Paulding, Prebie, Putnam, Shelby, Van Wert, Warren, Williams, R'Yandot
<br />FAX #: (937) 428-8890
<br />Anthem Blue Cross and Blue Shield To1Pdo mhio Connties:
<br />8333 Rockside Rd #200 OHIO: Erie, Huron, Lucas, Ottawa, Sandusky, Seneca, Wood
<br />Cleveland, OH 44125 MICHIGAN: NIonroe
<br />FAX #: (216) 573-4615
<br />Anthem Biue Cross and Blue Shield Youngstown Ohio Counties:
<br />2400 Mazket St OHIO: Belmont, Columbiana, Harrison, Jefferson, Mahoning, Trumbull
<br />oungstown, OH 44507 PENNSYLUANIA: Beaver, Lawrence, Mercer
<br />!v u. f1!nX742_2Cd1Z ixTRCT ViRC:TNTA• RrnnkP Hancnck. MarshalL Oh10
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