Medical Transition Care Benefit Request Form - Horizon Blue Cross 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Effective Date of Coverage and Policy Number at the top of the form. This information is crucial for processing your request.
3. Fill in your Employer Name, Employee/Retiree Name, and Address details. Ensure all names are spelled correctly to avoid any delays.
4. Provide your Member ID number and Retiree Date of Birth as indicated. This information helps verify your eligibility.
5. If applicable, include Dependent Name and Address details along with their Date of Birth and Relationship to you.
6. Indicate whether your current insurance company covers the requested services and if you have other health insurance.
7. In the section for the treating physician, enter their name, contact information, diagnosis details, and treatment plan. This section must be completed by your physician.
8. Finally, sign the authorization section to allow your physician to share necessary information with Horizon Blue Cross. Make sure to date your signature.

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