Manage Private Information

 HIPAA - Appointment of Representative (CMS Form)

Use this form to appoint someone as a member's representative in connection with making a claim or asserting a right under Title XVIII of the Social Security Act (the “Act”) and related provisions of Title XI of the Act. ID: CMS-1696

 HIPAA - Authorization for Disclosure of Private Information (non-Dental) to Authorization For Disclosure OR Request For Access To Protected Health Information

This form authorizes the use and disclosure of a member’s non-dental private information that is held by Horizon BCBSNJ and its business associates. ID: 32261

 HIPAA - Notification of Disclosures of Private Information to Plan Sponsor Employees

This form authorizes Horizon BCBSNJ to disclose a member’s private information to group employers. ID: 6846

 HIPAA - Request for Accounting of Disclosures of Private Information

This form is used to request an accounting of any disclosures of a member’s Private Information by Horizon BCBSNJ and its business associates. ID: 32262

 HIPAA - Request to Amend Private Information

Use this form to request a change be made to a member’s records held by Horizon BCBSNJ and its business associates. ID: 8069A

 HIPAA - Request to Represent a Deceased Member

Use this form to designate someone as a representative for a deceased member’s private information. ID: 32260

 HIPAA - Request to Terminate Confidential Communications

Use this form to request termination of the confidential communication of a member’s private information by Horizon BCBSNJ and its business associates. ID: 897

 HIPAA - Request to Terminate Personal Representative

Use this form to request termination of a representative that exists or was created for a member. ID: 8072A

 HIPAA Request for Appointment of Personal Representative

Use this form to designate someone as a representative for a member’s private information. ID: 8070A