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Braven Health℠ Forms

The forms below are designed to be used for your Braven Health patients. Please note that there are not Braven Health-specific versions of all form types. We will accept Horizon BCBSNJ branded forms for most scenarios.

PDF Consent Form - Out-of-Network (Braven Health)

This form must be completed by a referring doctor/other health care professional and signed by the Braven Health member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 40054

PDF Request Form - Braven Health Continuity of Practitioner Care for Medical Benefits

Use this form to request continuity of practitioner care for medical benefits for patients enrolled in Braven Health plans. ID: 40050

PDF Request Form – Professional/Institutional Inquiry, Request & Adjustment Mail Form (for Braven Health℠ patients)

Professional and Institutional providers may use this form to mail us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40111

PDF Request Form – Professional Provider Inquiry, Request & Adjustment FAX Form (for Braven Health℠ patients)

Professional providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40112

PDF Request Form – Hematologist/Oncologist Inquiry, Request & Adjustment FAX Form (for Braven Health℠ patients)

Hematology/Oncology providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40114

PDF Request Form – Institutional/Facility Inquiry, Request & Adjustment FAX Form (for Braven Health℠ patients)

Institutional providers may use this form to FAX us inquiries, claim adjustment requests, or requests to resolve or provide information about issues related to patients enrolled in Horizon BCBSNJ plans. ID: 40113