Provider Specialty Change Request Form - Horizon BCBSNJ
PROVIDER SPECIALTY CHANGE REQUEST FORM
Practitioners may use this form to request that we update our files to: change a provider specialty type; add an additional
provider specialty type for certain networks; or add a subspecialty or specialized service type.
Requests may take up to thirty days to process. Please provide at least thirty days in advance of the effective date of a
requested change. We are not responsible for the implementation of changes without proper advance notice. Requests
received without complete information or an authorized signature will not be processed.
Please submit this form as an attachment along with a completed copy of our Horizon Data Submission Template. For
details and instructions, visit DemographicUpdates.
Practitioner Name
Practitioner Date of Birth
Gender (Male/Female)
Practitioner Type1 NPI
Practitioner Degree
Currently Contracted Specialty
Group Practice Name
Group Practice Type 2 NPI
CHANGE MY PRACTITIONER SPECIALTY
For the network(s) checked below, change the above-noted specialty to
Horizon Managed Care Network and/or Horizon PPO Network
Horizon NJ Health Network
ADD A PRACTITIONER SPECIALTY
For the Horizon NJ Health Network, add specialty type
ADD A SUBSPECIALTY OR SPECIALIZED SERVICE TYPE
For the network(s) checked below, add subspecialty/specialized service type
Horizon Managed Care Network and/or Horizon PPO Network
Horizon NJ Health Network
List the name of certifying board for the above-noted specialty type, subspecialty/specialized service type.
Attestation
By signing and dating below, I authorize the above noted change/addition to my Horizon provider file.
Signature
Date of Signature
32263 - 02022023
Products are provided by Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ, Horizon Healthcare of New Jersey, Inc. (d/b/a Horizon NJ Health for Medicaid
line of business), Horizon Insurance Company and Healthier New Jersey Insurance Company d/b/a Braven Health. Communications may be issued by Horizon
Healthcare Services, Inc. d/b/a Horizon BCBSNJ in its capacity as administrator of programs and provider relations for its companies.
Horizon Healthcare of New Jersey, Inc. d/b/a Horizon NJ Health, Horizon Insurance Company, Healthier New Jersey Insurance Company d/b/a Braven Health and
Horizon Healthcare Services, Inc. d/b/a Horizon BCBSNJ are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross? and Blue
Shield? names and symbols are registered marks of the Blue Cross and Blue Shield Association. The Horizon? name and symbols are registered marks of Horizon
Blue Cross Blue Shield of New Jersey. ?2023 Horizon Blue Cross Blue Shield of New Jersey, Three Penn Plaza East, Newark, New Jersey 07105.
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