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Miscellaneous

PDF  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

PDF  Authorization Form - EDI/Electronic Transactions

Use this form to authorize electronic transactions between a trading partner and Horizon BCBSNJ. ID: 3193

PDF  COVID-19 Vaccine Form

COVID-19 Vaccination Administration

PDF  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

PDF  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

PDF  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

PDF  Communication Form - Clinicians

This form is used by a clinician to provide information about a patient.

PDF  Notification Form - High Risk Maternity Case

Use this form to provide Horizon BCBSNJ with information about a high-risk maternity case. ID: 8564

PDF  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

PDF  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