Update Personal Information
Request for Amendment of 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: CMC0008179 (0616)
Authorization For Disclosure OR Request For Access To Protected Health Information (PHI)
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: CMC0007942 (0516)
Request For Accounting Of Disclosures
This form is used to request an accounting of any disclosures of a member’s Private Information (PI) by Horizon BCBS and its business associates.
ID: 32262 (W0816)
Request for Appointment of Personal Representative
Use this form to designate someone as a representative for a member’s Private Information.
ID: 8070A (W0116)
Request to Terminate an Automatic or Appointed Personal Representative
Use this form to request termination of a representative that exists or was created for a member.
ID: 8072A (W1215)
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
Request to Represent a Deceased Member
Use this form to designate someone as a representative for a deceased member’s Private Information.
ID: 32260 (W0316)