Dental
Automated Clearinghouse Authorization Agreement
Automated Clearinghouse Authorization Agreement. ID: 8897
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
Dental - Patient Encounter Form
This is a Dental claim form used by the dental provider for patient encounters. ID: 2954
Dental Credentialing Application
This form is used by New Jersey dental providers to apply to Horizon BCBSNJ’s networks. ID: 32227
Dental Recruiting Request
Dental Recruiting Request ID: 9652
National Provider Identifier (NPI) Collection Form - Dental Group/Practice
National Provider Identifier (NPI) Collection Form - Dental Group/Practice ID: 19708
National Provider Identifier (NPI) Collection Form - Individual Dentist
National Provider Identifier (NPI) Collection Form - Individual Dentist ID: 19707
New Jersey Orthodontic Evaluation HLD (NJ-Mod2) Index Form
New Jersey Orthodontic Evaluation HLD (NJ-Mod2) Index Form
Orthodontic Referral Authorization
Dental providers use this form as a referral for orthodontic authorizations. ID: 8079
Periodontal Specialty Referral Authorization
Dental providers use this form as a referral for specialty periodontal authorizations. ID: 1649
Specialty Service Referral Authorization
Dental providers use this form as a referral for specialty service authorizations. ID: 8083
