Skip to main content

Inquiry / Request Forms

PDF  Request For Termination

ID: 32233

PDF  Request Form - Certificate of Creditable Coverage

Need new coverage without a pre-existing condition exclusion? Use this form to request the proper Horizon BCBSNJ Certificate. ID: 6793

PDF  Request Form - Dental - Credit for Deductible Carryover

If new members (and/or covered family members) have met all or part of their deductible under a prior dental plan, use this form to request that a credit be applied to their new plan. ID: 7263

PDF  Request Form - Dental - Recruit Provider

Give this form to a dentist to invite him/her to join one or more Horizon BCBSNJ dental networks. ID: 9652

PDF  Request Form - FSA Check Reissue Form

ID: 32223

PDF  Request Form - HRA Check Reissue Form

ID: 32224

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  Request Form - Medical - Transition Care Benefit

Use this form to request Transition Care benefits. ID: 7164

PDF  Request Form – Merck Members – Flexible Spending Account – Check Reissue

If a Flexible Spending Account (FSA) reimbursement check is not received, this form is used to request a new one. ID: 16115

PDF  Request for Continuance of Enrollment for Disabled Dependent

Members with a mentally-impaired or physically-disabled child can use this form to request that the child continues to be covered by the parent’s dental plan. ID: 9429

Attention SHBP/SEHBP members: You must use the SHBP/SEHBP Continuance of Enrollment application instead of this form.

If your dependent child is turning 26 during this calendar year, their coverage under your Horizon health benefits will end as of December 31. However, if your dependent child is turning 26 and not capable of self-support due to a mental or physical disability, you may request a continuance of enrollment for disabled dependent using this application form. You must complete Part 1, while your dependent’s attending physician must complete Part 2. Please be sure that every question is answered, and both Parts 1 and 2 are sent together. Missing information may result in processing delays or termination of coverage.

PDF  Request to have Medical Records Transferred

Member request to have medical records transferred to a doctor or other healthcare professional. ID: 7953