Dental

Use this form to enroll a new subscriber, or make a change to a current enrollment, to a Horizon BCBSNJ Medical or Dental plan for small groups.

ID: 6803 (06/19)

This is the Spanish version of the form to enroll a new subscriber, or make a change to a current enrollment, to a Horizon BCBSNJ Medical or Dental plan for small groups.

ID: 6803 (06/16)

This fillable form to request continuance of enrollment for a disabled dependent includes eligibility information.

ID: 9429 (W06/13)

This fillable form to request continuance of enrollment for a disabled dependent includes eligibility information.

ID: 9429 (W07/18)

This fillable form allows members to report deductible amounts under their prior Dental program, which can be carried over to a new Horizon plan.

ID: 7263 (W06/16)

Use this fillable cover page when faxing documents related to Internet Group enrollment.

ID: 8396 (W09/06)