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Manage Private Information Forms

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

PDF  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

PDF  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

PDF  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

PDF  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

PDF  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

PDF  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

PDF  HIPAA Request for Appointment of Personal Representative

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