Medical 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
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/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
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)
Fax Form - Internet Group Enrollment - Medical (North)
Fax Form - Internet Group Enrollment - Medical (North) ID: 8396
Fax Form - Internet Group Enrollment - Medical (South)
Fax cover sheet for the Internet Group Enrollment (South) process related to medical plans. ID: 8398
Horizon Health Insurance Claim Form
Horizon HMO, Horizon POS, Horizon Direct Access, Horizon EPO, Horizon PPO, Traditional, National Accounts and OMNIA Health Plan members use this form for medical claims. ID: 7190
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.
Plan Descriptions - Medical (Individual-Family Plans) (Spanish)
Plan Descriptions - Medical (Individual-Family Plans) (Spanish)
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
Request Form - Medical - Credit for Deductible Carryover
If new members (and/or covered family members) have met all or part of their deductible under a prior Medical plan, use this form to request that a credit be applied to their new plan. ID: 7239
Special Enrollment Period Supporting Document
Use this form for Special Enrollment period.
Submission Form - Internet Group Enrollment - Medical
This form provides group and payment information in the Internet Group Enrollment process. ID: 0803