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

 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.