Specialty Results and Recognition Contact Form

To join a Specialty R&R Program (for Endocrinology, Women's Health/OBGYN, Ophthalmology, and/or Cardiology) and receive incentive payments, please complete this contact form.
 
This is a voluntary program. A receipt of this completed survey validates your commitment to work with Horizon BCBSNJ to improve quality and receive incentives for reaching the targeted benchmarks.

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* 1. Practice name:

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* 2. Main contact name

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* 3. Please check all applicable specialties for your site:

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* 4. Address for check to be sent:

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* 5. Service Address (please complete if not the same as above):

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* 6. Tax ID:

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* 7. Fax number:

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* 8. Which means of communication is preferred?  Check all that apply

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* 9. Practice information:

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* 10. Are you enrolled in EFT for payments?

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