Use this form to set up your employer group's account for ACS/Mellon Health Savings Accounts.
Horizon HMO, Horizon POS and Horizon Direct Access, Horizon EPO and OMNIA Health Plan members use this form for medical claims. ID: 0834
Members of Horizon BCBSNJ PPO or Traditional plans use this form to file claims. ID: 7190
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
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
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
ID: 744Sp (0115)
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.
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
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