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) - 2023
ID: 744 With Peds (W0922)
Enrollment/Change Request Form – Spanish (Individuals-Families) - 2023
744 con Pediátrico (W0922)
Horizon Health Insurance Claim Form
Horizon HMO, Horizon POS, Horizon Medicare Advantage Group, Horizon Direct Access, Horizon EPO, Horizon PPO, Traditional, National Accounts and OMNIA Health Plan members use this form for medical claims. ID: 7190
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