Appointment Assistance Request Form

For help making an appointment with a provider, you can call us at 1-800-682-9090 (TTY 711), or submit the form below.

Required Fields

First Name

Last Name

Member ID #

Best phone to reach you

Email Address

What type of provider or specialist do you need?

Please provide your location (the address where you are currently living):

If you want an appointment with a specific provider, please give their first and last name.

Provider’s First Name

Provider’s Last Name

Address

City

State

Zip Code

County

Do you need help arranging transportation for health care visits?

Yes

Have you already contacted us to ask for help making an appointment?

If yes, please give the date you contacted Member Services.

Yes

Date (DD/MM/YY)

You can make a formal complaint. This is also called “filing a grievance”.

If you want to file a grievance, check the box below.

I want to file a grievance.

Appointment Assistance Request Form - Horizon NJ Health