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Authorization Forms

Forms and documents related to requesting or providing authorization.

Claim Forms

Claim forms, and claims-related forms and documentation including pre-determination of benefits forms and lists of eligible/ineligible expenses, etc.

Enroll / Elect / Apply Forms

Forms and documents related to enrolling, electing, or applying for participation in a plan or electronic transaction capability, etc.

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 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

Inquiry / Request Forms

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.

Manage Private Information Forms

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).

Prescription Drug Mail Order Forms

Order forms (eg, mail order forms for prescriptions).