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.
Broker-Of-Record Letter (Individual)
ID: 32332
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
Enrollment/Change Request Form – English (Individuals-Families) - 2018
ID: 744 With Peds (W1017)
Enrollment/Change Request Form – Spanish (Individuals-Families) - 2018
ID: 744 con peds (W1017)
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.
