‌

ALL

Select an audience to restrict the search

Enter the terms you wish to search for

searchbutton

Home
Members
Providers
Brokers
Employers

Contact Us
About Us
CAREERS
search_has_popup

READ FAQS MEMBER SIGN IN

Toggle menu

BACKback to www.horizonblue.com
MEMBERS
Health ProgramsHealth Programs
PlansPlans
Our NetworksOur Networks
FormsForms
WellnessWellness
Education CenterEducation Center
NewsNews
Tools & ServicesTools & Services
FIND A DOCTOR
MEMBER SIGN IN
SHOP FOR A PLAN

Health Programs
- AbleTo Support Program
  
  Cancer Program
  
  Case Management
  
  Chronic Care Program
  
  Horizon Behavioral Health
  
  Horizon Supportive Care Program
  
  Patient-Centered Programs
  
  Remote Patient Monitoring for COPD
Plans
- Accident Insurance
  
  Coverage Outside New Jersey
  
  Horizon Dental
  
  Horizon Pharmacy
  
  Horizon Vision
  
  Medical Plans
  
  Medicaid
  
  Medicare
  
  Pet Insurance
  
  SHBP and SEHBP Members
Our Networks
- Care Facilities
  
  Clinical Laboratory Services
  
  Horizon Care at Home
  
  Pharmacies
  
  Providers
  
  Radiology/Cardiology Imaging
  
  Sanitas Medical Centers
  
  Urgent Care Centers
Forms
- Search by Form Type
  
  Search by Frequently Used Forms
  
  Search by Plan Type
Wellness
- Living and Savings
  
  Maternity Program
  
  My Health Manager
Education Center
- Advance Directive
  
  Coverage decisions
  
  Gaining a better understanding of Prosthetics
  
  Making a Payment
  
  Medicare Advantage
  
  Member Handbooks
  
  Member Rights and Responsibilities
  
  NJ Individual Mandate
  
  Other Health Expense Plans
  
  Pharmacy and Prescriptions
  
  Preventive Health
  
  Unclaimed Property Due Diligence Letter
  
  Understanding Your Coverage
  
  Understanding Your OMNIA Health Plan
  
  Your Guide to Getting Care
  
  Your Health in Focus
News
- Member News
Tools & Services
- 24/7 Nurse Line
  
  Connect With Us Online
  
  Doctor and Hospital Finder
  
  Horizon Blue App
  
  Horizon CareOnline
  
  Horizon MyWay
  
  Identity Protection Services
  
  Our secure member website
  
  Personal Health Assistant
  
  The Power of Paperless
  
  Treatment Cost Estimator

Home
Members
›Forms
›Search by Plan Type
›Horizon NJ TotalCare (HMO D SNP) Forms

Search by Form TypeSearch by Form Type
Search by Frequently Used FormsSearch by Frequently Used Forms
Search by Plan TypeSearch by Plan Type

Horizon NJ TotalCare (HMO SNP) Forms

SNP Personal Representative Request Form

ID: Y0090_H8298_CMC0008380

Are you sure you want to leave this website?

You are leaving the Horizon Blue Cross Blue Shield of New Jersey website. Please click Continue to leave this website. Or, if you would like to remain in the current site, click Cancel.

CONTINUE link

#1 in Member Satisfaction among
Commercial Health Plans in NJ, 3 out of 4 Years

This website is operated by Horizon Blue Cross Blue Shield of New Jersey and is not New Jersey’s Health Insurance Marketplace. This website does not display all Qualified Health Plans available through Get Covered NJ. To see all available Qualified Health Plan options, go to the New Jersey Health Insurance Marketplace at Get Covered NJ.

Products are provided by Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ, Horizon Healthcare of New Jersey, Inc. (d/b/a Horizon NJ Health for Medicaid line of business) , Horizon Insurance Company and Healthier New Jersey Insurance Company d/b/a Braven Health. Communications may be issued by Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ in its capacity as administrator of programs and provider relations for its companies. Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health, Horizon Insurance Company, Healthier New Jersey Insurance Company d/b/a Braven Health and Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ are independent licensees of the Blue Cross and Blue Shield Association.

For J.D. Power 2020 award information, visit jdpower.com/awards.

Information in other Languages

Español
Polski
عربي
中文
Italiano
اردو
한국어
Русский язык
Português
Tagalog
हिंदी
Kreyòl ayisyen
ગુજરાતી
Français
Tiếng Việt

FAMILY OF COMPANIES

Horizon BCBSNJ Dental
Horizon Casualty Services
Horizon NJ Health

® 2020 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.

Applicable Products:
Commercial PPO/EPO &
Exchange POS/EPO

Applicable Products:
Commercial HMO & POS

Horizon NJ TotalCare (HMO SNP) Forms

CNA Form DSNP

SNP Personal Representative Request Form

Health Needs Survey