Medical Forms

PDF  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.

PDF  Claim Form - Medical - HMO-POS-Direct Access – EPO – OMNIA Health Plans

Horizon HMO, Horizon POS and Horizon Direct Access, Horizon EPO and OMNIA Health Plan members use this form for medical claims. ID: 0834

PDF  Claim Form - Medical - PPO-Traditional

Members of Horizon BCBSNJ PPO or Traditional plans use this form to file claims. ID: 7190

PDF  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

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 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 - 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  Enrollment/Change Request Form – English (Individuals-Families) - 2018

ID: 744 With Peds (W1017)

PDF  Enrollment/Change Request Form – Spanish (Individuals-Families) - 2018

ID: 744 con peds (W1017)

PDF  Fax Form - Internet Group Enrollment - Medical (North)

Fax Form - Internet Group Enrollment - Medical (North) ID: 8396

PDF  Fax Form - Internet Group Enrollment - Medical (South)

Fax cover sheet for the Internet Group Enrollment (South) process related to medical plans. ID: 8398

PDF  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.

PDF  Plan Descriptions - Medical (Individual-Family Plans) (Spanish)

Plan Descriptions - Medical (Individual-Family Plans) (Spanish)

PDF  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

PDF  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

PDF  Special Enrollment Period Supporting Document

Use this form for Special Enrollment period.

PDF  Submission Form - Internet Group Enrollment - Medical

This form provides group and payment information in the Internet Group Enrollment process. ID: 0803