Claim forms and claims-related forms.
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)
ID: ID 3200 (w1106)
When you are submitting expenses for more than one family member, please use a separate claim form for each person. It is suggested that you make copies for your own use before you submit the original bills.
ID: 7190 (0319)
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 (0320)
This form will assist you in obtaining a pre-determination as to whether a particular service or supply will be eligible under the Sanofi Medical Plan and if it meets the medical necessity and reasonable and customary guidelines.
ID: 3202 (W0120) Sanofi PD
ID: 9429 (W0718)