Inquiry / Request Forms
Request For Termination
ID: 32233
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
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
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
Request Form - FSA Check Reissue Form
ID: 32223
Request Form - HRA Check Reissue Form
ID: 32224
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
Request Form - Medical - Transition Care Benefit
Use this form to request Transition Care benefits. ID: 7164
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
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.
Request to have Medical Records Transferred
Member request to have medical records transferred to a doctor or other healthcare professional. ID: 7953