Small Group (2-50)
Use this form to complete an employer set-up for an ACS/Mellon Health Savings Account (HSA).
ID: CMC0007942 (05/16)
Use this form to enroll a new subscriber, or make a change to a current enrollment, to a Horizon BCBSNJ Medical or Dental plan for small groups.
ID: 6803 (06/19)
This provides confirmation of Health Savings Account (HSA) selection and summarizes account advantages.
ID: 5890 (W01/12)
Members can use this fillable form to report deductible credits to carry over, for the current calendar year only.
ID: 7239 (W0616)
Members can complete this form and present to a physician, medical practice or institution to initiate a release or transfer of medical record information to another physician, medical practice or institution.
ID: 7953 (W0616)
This fillable form to request continuance of enrollment for a disabled dependent includes eligibility information.
ID: 9429 (W07/18)
Use this form to submit checks for Internet Group enrollments.
ID: CM0008179 (06/16)
This is the Spanish version of the form to enroll a new subscriber, or make a change to a current enrollment, to a Horizon BCBSNJ Medical or Dental plan for small groups.
ID: 6803 (06/16)
This form must be completed by the account or attorney of a Small Employer with 1 to 50 employees that has affiliated companies, subsidiaries or common ownership.
ID: 23339 (W05/18)
Use this fillable form with clients applying for a small group health plan (15 to 50 eligible employees).
ID: 40106 (12/21)
Use this form if applying for Small Business Health Options Program (SHOP) coverage.
ID: 32328 (11/21)
This form is to certify that small group employer criteria is met.
ID: 32285 (W11/17)
Use this form if applying for standard health insurance coverage along with a Health Plus Plan.
ID: 32336 (W03/18)
Use this form if applying for a Health Plus Plan.
ID: 32338 (W03/18)
Horizon HMO, Horizon POS, Horizon Direct Access, Horizon EPO, Horizon PPO, Traditional, National Accounts and OMNIA Health Plan members use this form for medical claims.
ID: 7190 (09/21)
This is a Spanish version of the application form for standard health insurance coverage.
ID: 32327 (W11/17)
Use this form if applying for standard health insurance coverage.
ID: 32327 (11/21)
Members can use this fillable agreement authorizing Horizon Blue Cross Blue Shield of New Jersey to debit a checking account.
ID: 8977 (W04/13)