Manage Private Information
Authorization for Disclosure OR Request For Access to Protected Health Information
Use this form to authorize the use and disclosure of your private information (PI) held by Horizon.
ID: 32261
Authorization for Disclosure of Protected Health Information (PHI) — Dental Only
Use this form to authorize the use and disclosure of a member’s dental Protected Health Information that is held by Horizon BCBSNJ and its business associates.
ID: 5418 (W0616)
Request for Accounting of Disclosures
To request an Accounting of Disclosures of your Private Information by Horizon Blue Cross Blue Shield of New Jersey and its business associates, please complete the information below, sign in the space provided and return to Horizon BCBSNJ
ID: 32262
Request for Appointment of Legal Personal Representative
Use this form to let another person handle your health care needs which includes allowing full access to your personal health information, changes to your health care coverage, as well as receiving your health care mail.
ID: 32426 (0219)
Request for Appointment of Limited Personal Representative
Use this form if you wish to allow your personal health information to be disclosed to the person named below so they can assist you with your health care and payment for health care. This person will not be permitted to make policy changes.
ID: 32423 (0419)
Solicitud de nombramiento de representante personal limitado para un asegurado
Utilice este formulario si desea permitir que su información de salud personal sea divulgada a la persona nombrada abajo para que pueda ayudarlo con su informacion personal de salud y el pago de la atención médica. Esta persona no podrá realizar cambios en la póliza.
ID: 32423
