Enroll / Elect / Apply
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 Form - Dental (Small Groups)
Use this form to enroll a new subscriber to a Horizon BCBSNJ Dental plan for small groups. ID: 7546
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
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)
Medicare Advantage and Part D Group Enrollment Form
ID: HORAP093
Medicare Group Employer Application Form
ID: Y0090
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
