Dental Forms

PDF  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

PDF  Enrollment Form - Dental (Small Groups)

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

PDF  Enrollment Kit - Medical (Small Groups)

Use this form to enroll a new subscriber to a Horizon BCBSNJ Medical plan for small groups. ID: 7215

PDF  Enrollment/Change Request Form - Dental (NJ)

Use this form to enroll new members or to make a change to an existing enrollment in a Horizon BCBSNJ dental plan. ID: 2149

PDF  Enrollment/Change Request Form - Medical and Dental (Mid-Size and Large Groups)

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 mid-size and large groups. ID: 6859

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

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

PDF  Request Form - Dental - Credit for Deductible Carryover

If new members (and/or covered family members) have met all or part of their deductible under a prior dental plan, use this form to request that a credit be applied to their new plan. ID: 7263

PDF  Request Form - Dental - Recruit Provider

Give this form to a dentist to invite him/her to join one or more Horizon BCBSNJ dental networks. ID: 9652

PDF  Request for 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 continues to be covered by the parent’s dental plan. ID: 2407

PDF  Request for Continuance of Enrollment for Disabled Dependent (Groups 51 Plus)

Members with a mentally-impaired or physically-disabled child can use this form to request that the child continues to be covered by the parent’s dental plan. ID: 9429