Horizon BCBSNJ - Member Downloadable Forms

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Downloadable Forms

As a service to our members, we are making the most commonly requested forms available for download. The documents are available in an Adobe® Acrobat® portable document format (PDF). Simply click on the title of the form you wish to download.

Claim Forms

	Medical Claim Form - HMO / POS / Direct Access (0834)
	Medical Claim Form - PPO & Traditional (7190)
	Medical Claim Form - NJ Plus (0737)
	Medical Claim Form - SHBP Traditional (0704)
	Medical Claim Form - SHBP NJ DIRECT (2642)
	Dental Claim Form (7902)

Pharmacy Forms

	Prescription Claim Form (14694)
	Prescription Mail Order Form (13598)
	Prescription Mail Order Form - Spanish (15753)

FSA & HSA Plan Forms

FSA Claim Form (6518)

HIPAA

	Authorization for Disclosure of Protected Health Information (3566)
	Transfer of Medical Records (7953)
	Request for Access to Private Information Form (8067A)
	Request for Accounting Disclosures (8068A)
	Request for Amendment of Private Information (8069A)
	Request for Confidential Communications (8066A)
	Request for Personal Representative (8070A)
	Request for Termination of Confidential Communications (897)
	Request to Represent a Deceased Member (8038A)
	Request to Terminate Personal Representation (8072A)

Dental Forms

	Dentist Recruiting Request Form for NJ (9652)
	Employee Dental Application for Enrollment or Change for NJ (4555)
	Authorization for Disclosure of Protected Health Information (5418)

Misc. Forms

	Horizon Centurion Application (1636)
	Individual Direct Access Member Handbook
	Dental Deductible Carryover Credit Report for NJ (7263)