Referral Program Procedure To invite your dentist to join one or more of Horizon Blue Cross Blue Shield of New Jersey’s dental networks, simply present him or her with this Recruiting Request Form. If your dentist is interested in joining, he or she may mail or fax this form to Horizon Blue Cross Blue Shield of New Jersey for consideration. If your dentist meets Horizon Blue Cross Blue Shield of New Jersey requirements and becomes a participating dentist, you will be eligible to receive the highest level of benefits from your dental program when you use this dentist. How does the program work? 1. Take this Recruiting Request Form to your dentist. If your dentist is not in the network, he or she may call 1-800-4DENTAL to request an application or may complete and mail or fax the other side of this form to receive more information. 2. A dentist’s returned Recruiting Request Form does not signify acceptance to the network. All prospective dentists are subject to Horizon Blue Cross Blue Shield of New Jersey’s credentialing requirements. Once a dentist has applied for participation, the request form will be reviewed and the information provided will be verified. The Horizon Blue Cross Blue Shield of New Jersey network has many excellent dentists from which to choose. Whether you are looking for convenient access from your workplace or proximity to your home, one is sure to meet your needs. Dentist Name: ___________________________________________________________ ________________________ _________ Last First MI Group Practice Name: ______________________________________________________________________________________ (if applicable) Dentist’s Specialty: _________________________________________________________________________________________ Address: ___________________________________________________________________________________________________ City: _________________________________________ County: ______________________ State: ________ ZIP: ____________ Telephone number: _______ - _______ - _____________ Your Name: _____________________________________________________________ ________________________ _________ Last First MI Your Company’s Name: _____________________________________________________________________________________ Date of Request: _____ / _____ / ________ Please send completed forms to: Professional Relations Department Horizon BCBSNJ Dental Programs Three Penn Plaza East PP-04Q Newark, NJ 07105-2200 (Fax): 973-466-6451 MM DD YYYY 9652 (W0212) Services and products may be provided by Horizon Blue Cross Blue Shield of New Jersey or Horizon Healthcare Dental, Inc., each of which is an independent licensee of the Blue Cross and Blue Shield Association. Horizon Healthcare Dental Inc., is a subsidiary of Horizon Blue Cross Blue Shield of New Jersey. Recruiting Request Form Dental Programs Three Penn Plaza East PP-04Q Newark, NJ 07101-1938 1-888-667-4547 www.HorizonBlue.com You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer, choose File > Save As to rename the file and save the form with your information to your computer.

Dental Programs Recruiting Request Form - Horizon Blue Cross … · Horizon BCBSNJ Dental Programs Three Penn Plaza East PP-04Q Newark, NJ 07105-2200 (Fax): 973-466-6451 MM DD YYYY

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Page 1: Dental Programs Recruiting Request Form - Horizon Blue Cross … · Horizon BCBSNJ Dental Programs Three Penn Plaza East PP-04Q Newark, NJ 07105-2200 (Fax): 973-466-6451 MM DD YYYY

Referral Program Procedure

To invite your dentist to join one or more of Horizon Blue Cross Blue Shield of New Jersey’s dental networks,simply present him or her with this Recruiting Request Form. If your dentist is interested in joining, he or she maymail or fax this form to Horizon Blue Cross Blue Shield of New Jersey for consideration. If your dentist meetsHorizon Blue Cross Blue Shield of New Jersey requirements and becomes a participating dentist, you will beeligible to receive the highest level of benefits from your dental program when you use this dentist.

How does the program work?

1. Take this Recruiting Request Form to your dentist. If your dentist is not in the network, he or she may call 1-800-4DENTAL to request an application or may complete and mail or fax the other side of this form toreceive more information.

2. A dentist’s returned Recruiting Request Form does not signify acceptance to the network. All prospectivedentists are subject to Horizon Blue Cross Blue Shield of New Jersey’s credentialing requirements. Once adentist has applied for participation, the request form will be reviewed and the information provided willbe verified.

The Horizon Blue Cross Blue Shield of New Jersey network has many excellent dentists from which tochoose. Whether you are looking for convenient access from your workplace or proximity to your home,one is sure to meet your needs.

Dentist Name: ___________________________________________________________ ________________________ _________Last First MI

Group Practice Name: ______________________________________________________________________________________(if applicable)

Dentist’s Specialty: _________________________________________________________________________________________

Address: ___________________________________________________________________________________________________

City: _________________________________________ County: ______________________ State: ________ ZIP: ____________

Telephone number: _______ - _______ - _____________

Your Name: _____________________________________________________________ ________________________ _________Last First MI

Your Company’s Name: _____________________________________________________________________________________

Date of Request: _____ / _____ / ________

Please send completed forms to:

Professional Relations DepartmentHorizon BCBSNJ Dental ProgramsThree Penn Plaza East PP-04QNewark, NJ 07105-2200

(Fax): 973-466-6451

MM DD YYYY

9652 (W0212)Services and products may be provided by Horizon Blue Cross Blue Shield of New Jersey or Horizon Healthcare Dental, Inc., each of which is an independent licensee of the Blue Cross and Blue Shield Association. Horizon Healthcare Dental Inc., is a subsidiary of Horizon Blue Cross Blue Shield of New Jersey.

Recruiting RequestForm

Dental Programs

Three Penn Plaza East PP-04QNewark, NJ 07101-19381-888-667-4547www.HorizonBlue.com

You may complete the required fields below online and then save or print a copy for submission. To save a completed copy to your computer, choose File > Save As to rename the file and save the form with your information to your computer.