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
