Consent

 Consent Form - Out-Of-Network (Spanish)

This form must be completed by a referring doctor/other health care professional and signed by the member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 2180S

 Consent Form - Out-Of-Network

This form must be completed by a referring doctor/other health care professional and signed by the member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 2180

 Consent Form - Representation in Appeals

This form provides or revokes consent to representation in an appeal of an adverse UM determination, as allowed by N.J.S.A. 26:25-11, and release of personal information to DOBI, its contractors for the Independent Health Care Appeals Program, and independent contractors reviewing the appeal. ID: dobiihcaparb