Medical Forms
Claim Form - BlueCard
Members use this form to file a claim if they received covered medical services outside the U.S., Puerto Rico, and the U.S. Virgin Islands. ID: N-12-42
Claim Form - HMO / POS / Direct Access / EPO / OMNIA Health Plans
Horizon HMO, Horizon POS and Horizon Direct Access, Horizon EPO and OMNIA Health Plan members use this form for medical claims. ID: 0834
Claim Form - National Accounts
National Account members use this form to file a medical claim. ID: 6044
Claim Form - PPO / Traditional
Members of Horizon BCBSNJ PPO or Traditional plans use this form to file claims. ID: 7190
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) - 2018
ID: 744 With Peds (W1017)
Enrollment/Change Request Form – Spanish (Individuals-Families) - 2018
ID: 744 con peds (W1017)
List - BlueCard Minute Clinics (National Accounts)
List of participating BlueCard® Minute Clinics.
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
