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Horizon claim form 2026

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The document is a Horizon Managed Care Health Insurance Claim Form that provides instructions for insured individuals to submit claims for medical expenses. It includes sections for personal information of the insured and patient, details about other insurance coverage, and an authorization section for benefit assignment. The form requires itemized bills for services rendered and outlines necessary information to avoid claim rejection. Additionally, it contains important notes on submitting claims for multiple family members, Medicare coordination, and fraud warnings.

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Click ‘Get Form’ to open the horizon claim form in the editor.
Begin by filling out the Insured’s Information section. Enter the last name, first name, date of birth, sex, identification number, address, telephone number, employer’s name, and insurance plan name.
If the patient is different from the insured, complete the Patient’s Information section. Include their last name, first name, date of birth, sex, telephone number, address, relationship to insured, and patient status.
In the Other Insurance Information section, provide details about any additional insurance plans if applicable. Fill in the policy holder's information as required.
Review and complete the Authorization section by certifying that all information is correct. Ensure you sign and date where indicated.
Attach any necessary itemized bills for covered services or supplies before submitting your claim.

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