Enroll / Elect / Apply

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/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  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  Medicare Advantage and Part D Group Enrollment Form

ID: HORAP093

PDF  Medicare Group Employer Application Form

ID: Y0090

PDF  Medicare Prescription Drug Plan Group Enrollment Form

ID: HORAP094

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