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Credentialing

PDF  Americans with Disabilities Act (ADA) Provider Survey

As part of joining our network(s), a copy of this survey must be completed for each practice location at which a physician (MD/DO) or other healthcare professional practices. ID: 32209

PDF  Behavioral Health Practitioner Supplemental Information

Behavioral Health practitioners use this form to provide information about their practice as part of the credentialing process as well as to help us make clinically appropriate referrals. ID: 32443

PDF  Continuity of Care Coverage Agreement

Physicians who limit their practice to providing services only in their office use this form to advise us of an established arrangement with other participating physicians/groups to care for patients requiring acute care at a network hospital, thereby satisfying our credentialing requirement to have network hospital privileges. ID: 5714

PDF  Hospital-Based Practitioners

Physicians and other healthcare professionals who are affiliated with a hospital-based practice may use this form to join a Horizon BCBNJ participating network. ID: 32255

PDF  Provider Network Special Needs Survey

A copy of this survey must be completed by physicians (MD/DO) and other healthcare professionals who are seeking to join our network(s). ID: 32210

PDF  Requirements for Other Healthcare Professionals (not an MD or DO) Checklist

Other healthcare professionals must complete this form to help ensure that all information/documentation is included in a request to join the Horizon Managed Care Network and/or the Horizon PPO Network. ID: 32244

PDF  Requirements for Physicians (MD or DO) Checklist

Physicians (MDs and DOs) must complete this form to help ensure that all information/documentation is included in a request to join the Horizon Managed Care Network and/or the Horizon PPO Network. ID: 32214

PDF  Statement of Arrangement for Controlled Dangerous Substances Drug Enforcement Agency (DEA) License

Physicians without a current NJ CDS Certificate use this form to document their arrangement with another participating physician to prescribe controlled dangerous substances on his/her behalf. ID: 5006

PDF  Statement of Arrangement for Controlled Dangerous Substances NJ CDS Certificate

Physicians without a current, unrestricted DEA License use this form to document their arrangement with another participating physician to prescribe controlled dangerous substances on his/her behalf. ID: 5005

PDF  Statement of Collaboration

Certified Nurse Midwives, Certified Registered Nurse Anesthetists, Advanced Practice Nurses and Physician Assistants use this form to establish a consultative, collaborative management and referral relationship with an appropriate Horizon BCBSNJ participating physician. ID: 5712