Authorizations
Authorization Form - Spending-Savings Accounts - Flexible Spending Account - Direct Deposit
This form authorizes Horizon BCBSNJ to make a bank account deposit for a Flexible Spending Account (FSA). ID: 8314
Authorization Form - VeriPoint Application Verification
This form authorizes Horizon BCBSNJ to collect information supplied by a provider on their application. ID: 1090
Clinical Information Cover Sheet – Authorization Request
Use this cover sheet when uploading clinical/medical record information through Horizon BCBSNJ’s online utilization management tool to support an Authorization request. ID: 32039
Clinical Information Cover Sheet – Medical Necessity Determination Request
Use this cover sheet when uploading clinical/medical record information through Horizon BCBSNJ’s online utilization management tool to support a Medical Necessity Determination request. ID: 32038
NJ State Police Annual Medical History
Please use this form for NJ State Police Annual Medical History. ID: sp117
Orthodontic Referral Authorization
Dental providers use this form as a referral for specialty service authorizations. ID: 8083
Periodontal Specialty Referral Authorization
Dental providers use this form as a referral for specialty periodontal authorizations. ID: 1649
Request Form - Authorization for EPOETIN ALPHA (Epogen/Procrit) DARBEPOETIN ALPHA (Aranesp)
Use this form to request authorization of the medical necessity of EPOETIN ALPHA (Epogen/Procrit) DARBEPOETIN ALPHA (Aranesp). ID: 9395
Request Form - Authorization for Post-Acute Facility Admission
Use this form to request authorization for admission to a post-acute (Acute Rehab, Subacute, SNF or LTAC) facility. ID: 4155
Request Form - Authorization for Post-Acute Facility Continued Stay
Use this form to request an extension for a member's stay in a post-acute facility. ID: 6637
Specialty Service Referral Authorization
Dental providers use this form as a referral for specialty service authorizations. ID: 8083
