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Medical Forms

PDF  Claim Form - Reimbursement - Orally Administered Cancer Medication Coverage

Use this form to request reimbursement for cancer medication. ID: 5337

PDF  Horizon Health Insurance Claim Form

Horizon HMO, Horizon POS, Horizon Direct Access, Horizon EPO, Horizon PPO, Traditional, National Accounts and OMNIA Health Plan members use this form for medical claims. ID: 7190

PDF  Request Form - 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 - Transition Care Benefit

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