Forms and documents related to requesting or providing authorization.
Claim forms, and claims-related forms and documentation including pre-determination of benefits forms and lists of eligible/ineligible expenses, etc.
Forms and documents related to enrolling, electing, or applying for participation in a plan or electronic transaction capability, etc.
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
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
Use this form to request a change be made to a member’s records held by Horizon BCBSNJ and its business associates.
ID: 8069A
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
Use this form to request termination of a representative that exists or was created for a member.
ID: 8072A
Use this form to designate someone as a representative for a member’s private information.
ID: 8070A
Forms and documents related to making inquiries or submitting various types of requests including requests for changes to an existing enrollment, requests for a predetermination for an upcoming medical or dental expense, request for authorization, etc.
Health Insurance Portability and Accountability Act (HIPAA) forms used by the member or the member's representative(s) to manage the member’s private health information (PHI).
Order forms (eg, mail order forms for prescriptions).
