Miscellaneous
Application - Medical - EFT Application for Ancillary Facilities
Medical providers use this form to establish Automated Clearing House (ACH) electronic funds transfer (EFT) from Horizon BCBSNJ. ID: 5922
Authorization Form - EDI/Electronic Transactions
Use this form to authorize electronic transactions between a trading partner and Horizon BCBSNJ. ID: 3193
Checklist - EDI Services Trading Partner - 835 Transaction
This checklist provides information to set up EDI capabilities for the EDI 835 transaction between a provider and Horizon BCBSNJ. ID: 3192
Checklist - EDI Services Trading Partner
This is a checklist that provides information to set up EDI capabilities between a provider and Horizon BCBSNJ. ID: 3191
Checklist - Hospital Discharge Transition Form
Use this checklist to provide Horizon BCBSNJ information about a patient who is being discharged from a hospital. ID: 5313
Collection Form - National Provider Identifier - Facility-Group-Practice
Facilities, groups and practices use this form to supply information regarding their National Provider Identifier (NPI). ID: 19419
Collection Form - National Provider Identifier - Individual Practitioner-Physician
Individual practitioners/physicians use this form to supply information regarding their National Provider Identifier (NPI). ID: 19418
Communication Form - Clinicians
This form is used by a clinician to provide information about a patient.
Notification Form - High Risk Maternity Case
Use this form to provide Horizon BCBSNJ with information about a high-risk maternity case. ID: 8564
Physician Authorization to Participate in Physical Agility Testing Form
Please use this form for NJ State Police Physician Authorization to Participate in Physical Agility Testing. ID: SP-116
Report Form - Physical and Occupational Therapy - Functional Progress
Physical and occupational therapists use this form to report the functional progress of a patient. ID: 4426
