Update Personal Information


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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)


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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)


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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)


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Request for Appointment of Personal Representative

Use this form to designate someone as a representative for a member’s Private Information.

ID: 8070A (W0116)


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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)


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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


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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)