Forms

Medical Forms

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New Jersey SHBP members with NJ DIRECT use this form to file claims.

ID: 2642

Use this form to request Transition Care benefits.

ID: 7164

If new members (and/or covered family members) have met all or part of their deductible under a prior Medical plan, use this form to request that a credit be applied to their new plan.

ID: 7239

This form authorizes Horizon BCBSNJ to report specific information about beneficiaries to the Centers for Medicare & Medicaid Services (CMS), as a CMS mandate requires of group health insurance plans. CMS uses this information to properly coordinate payment of benefits among health plans so that claims are paid accurately.

ID: 4984

SHBP members in the New Jersey State Police use this form to provide medical history information.

ID: SP 117

New Jersey SHBP members with Horizon Medicare Advantage NJ DIRECT (PPO) should use this form to file claims.

ID: 2642 (W0417)