Small Group (2-50)

Use this form to complete an employer set-up for an ACS/Mellon Health Savings Account (HSA).

ID: CMC0007942 (05/16)

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 provides confirmation of Health Savings Account (HSA) selection and summarizes account advantages.

ID: 5890 (W01/12)

Members can use this fillable form to report deductible credits to carry over, for the current calendar year only.

ID: 7239 (W0616)

Members can complete this form and present to a physician, medical practice or institution to initiate a release or transfer of medical record information to another physician, medical practice or institution.

ID: 7953 (W0616)

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

ID: 9429 (W07/18)

Use this form to submit checks for Internet Group enrollments.

ID: CM0008179 (06/16)

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 form must be completed by the account or attorney of a Small Employer with 1 to 50 employees that has affiliated companies, subsidiaries or common ownership.

ID: 23339 (W05/18)

Use this fillable form with clients applying for a small group health plan (15 to 50 eligible employees).

ID: 40106 (12/21)

Use this form if applying for Small Business Health Options Program (SHOP) coverage.

ID: 32328 (11/22)

This form is to certify that small group employer criteria is met.

ID: 32285 (W11/17)

Use this form if applying for standard health insurance coverage along with a Health Plus Plan.

ID: 32336 (W03/18)

Use this form if applying for a Health Plus Plan.

ID: 32338 (W03/18)

Horizon HMO, Horizon POS, Horizon Direct Access, Horizon EPO, Horizon PPO, Traditional, National Accounts and OMNIA Health Plan members use this form for medical claims.

ID: 7190 (09/21)

This is a Spanish version of the application form for standard health insurance coverage.

ID: 32327 (W11/17)

Use this form if applying for standard health insurance coverage.

ID: 32327 (11/22)

Members can use this fillable agreement authorizing Horizon Blue Cross Blue Shield of New Jersey to debit a checking account.

ID: 8977 (W04/13)