Claim forms and claims-related forms.

Pdf Image

Medical Transition Care Benefit Request

Transition Care, also referred to as treatment in progress, is a benefit that allows new subscribers and covered dependents to receive medical care by non-participating providers at the in-network benefit level for treatment of an acute injury or illness. Transition care is short term and not intended to replace the regular provisions of the program.

ID: 7164 (W0312)

Pdf Image

Coordination of Benefits

This form authorizes Horizon BCBS to obtain any and all medical records and information from providers of service and/or hospitals, relating to the subscriber and eligible dependents, to the extent required to administer the Plan.

ID: 3247 (W0312)