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Horizon Managed Care Health Insurance Claim Form THIS FORM CAN BE DOWNLOADED FROM OUR WEB SITE AT www. I the undersigned authorize and request Horizon Blue Cross Blue Shield of New Jersey to make payment for benefits which may be due herein to NAME OF HEALTH CARE PROFESSIONAL SIGNATURE OF INSURED TAX NUMBER Required NPI NUMBER SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION 0834 W0509 An Independent Licensee of the Blue Cross and Blue Shield Asso.

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