Medical Forms

 Claim Form - Reimbursement - Orally Administered Cancer Medication Coverage

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

 Enrollment/Change Request Form – English (Individuals-Families) - 2019

ID: 744 With Peds (W0810)

 Enrollment/Change Request Form – Spanish (Individuals-Families) - 2018

ID: 744 con peds (W1017)

 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

 Plan Descriptions - Individual-Family Plans (Spanish)

 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

 Request Form - Transition Care Benefit

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