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Consent

PDF  Consent Form - Out-Of-Network (Horizon BCBSNJ)

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

PDF  Consent Form - Out-of-Network (Horizon Medicare Advantage)

This form must be completed by a referring doctor/other health care professional and signed by a Horizon Medicare Advantage member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 40054H

PDF  Consent Form - Out-of-Network (Braven Health)

This form must be completed by a referring doctor/other health care professional and signed by the Braven Health member at the time a referral is made to a nonparticipating doctor, facility or other health care provider (including clinical labs). ID: 40054

PDF  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

PDF  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