Manage Private Information Forms

 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 - 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