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.
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
Claim Form - Medical - PPO-Traditional
Members of Horizon BCBSNJ PPO or Traditional plans use this form to file claims. ID: 7190
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 Kit - Medical (Small Groups)
Use this form to enroll a new subscriber to a Horizon BCBSNJ Medical plan for small groups. ID: 7215
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 – Spanish (Individuals-Families)
ID: 744Sp (0115)
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 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
