Individual & Family Forms
ACS/Mellon Health Savings Account Employer Discovery Document / Set-up Form
Use this form to set up your employer group's account for ACS/Mellon Health Savings Accounts.
Confirmation of HSA Selection
Use this form to confirm your employer group's selection of a Horizon Blue Cross Blue Shield of New Jersey MyWay Health Savings Account for tax-free saving and health care spending. ID: HOR5890
Dental and Vision Non-Group Enrollment/Change Request
Use this form to enroll a new subscriber to a Horizon BCBSNJ Medical plan for small groups. ID: 845
Enrollment/Change Request Form – Spanish (Individuals-Families)
ID: 744Sp (0115)
Horizon Healthcare Services, Inc. Declaration of Understanding
New Jersey law required that contract holders that apply for or renew a high deductible health plan which qualified medical expenses are paid using a health savings account receive a "Declaration of Understanding" that describes certain features of the plan.
