Dental

PDF  Automated Clearinghouse Authorization Agreement

Automated Clearinghouse Authorization Agreement. ID: 8897

PDF  Change Request Forms - Provider and/or Office File Info

This form is used by dental providers to update their file maintained by Horizon BCBSNJ. ID: 2813

PDF  Dental - Patient Encounter Form

This is a Dental claim form used by the dental provider for patient encounters. ID: 2954

PDF  Dental Credentialing Application

This form is used by New Jersey dental providers to apply to Horizon BCBSNJ’s networks. ID: 32227

PDF  Dental Recruiting Request

Dental Recruiting Request ID: 9652

PDF  National Provider Identifier (NPI) Collection Form - Dental Group/Practice

National Provider Identifier (NPI) Collection Form - Dental Group/Practice ID: 19708

PDF  National Provider Identifier (NPI) Collection Form - Individual Dentist

National Provider Identifier (NPI) Collection Form - Individual Dentist ID: 19707

PDF  New Jersey Orthodontic Evaluation HLD (NJ-Mod2) Index Form

New Jersey Orthodontic Evaluation HLD (NJ-Mod2) Index Form

PDF  Orthodontic Referral Authorization

Dental providers use this form as a referral for orthodontic authorizations. ID: 8079

PDF  Periodontal Specialty Referral Authorization

Dental providers use this form as a referral for specialty periodontal authorizations. ID: 1649

PDF  Specialty Service Referral Authorization

Dental providers use this form as a referral for specialty service authorizations. ID: 8083