Small Group Forms

Authorization Form - Waive Health Benefits Coverage (Small Groups)

Use this form to waive/decline health benefits coverage. ID: 32286

Certification Form - Small Group Employer

This form is to certify that small group employer criteria is met. ID: 32285

Enrollment Change/Request form Medical/Dental/Vision (Small Groups)

Use this form to enroll a new subscriber, or make a change to a current enrollment, to a Horizon BCBSNJ Medical, Dental, or Vision plan for small groups. ID: 6803

Enrollment Form - Dental (Small Groups)

Use this form to enroll a new subscriber to a Horizon BCBSNJ Dental plan for small groups. ID: 7546

Fax Form - Internet Group Enrollment - Dental (Small Group)

Fax cover sheet for the Internet Group Enrollment (North) process related to medical plans. ID: 7210

Group Enrollment Exchange Request Form - Spanish

ID: 6803

Horizon Health Plus Plan (SEHPP Bundle)

Use this form if applying for a Health Plus Plan.

Horizon Health Plus Plan with Medical (SEHP and SEHP Bundle)

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

Request Form - Medical - Continuance of Enrollment for Disabled Dependent (Groups 2-50)

Members with a mentally-impaired or physically-disabled child can use this form to request that the child be covered by the parent’s medical plan. ID: 2407