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Authorization For Disclosure OR Request For Access To Protected Health Information

Complete this form to authorize the use and disclosure of your private information (PI) held by Horizon.

ID: 32261

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.

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).

Federal Employee Program Privacy Forms

Prescription Drug Mail Order Forms

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