Forms

HIPAA Forms

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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: 32261 (W0316)

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

ID: 32260 (W0316)

This form is used to request an accounting of any disclosures of a member’s Private Information by Horizon BCBSNJ and its business associates.

ID: 32262 (W0316)

Use this form to request a change be made to a member’s records held by Horizon BCBSNJ and its business associates.

ID: 8069A

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

ID: 8070A (W0116)

Use this form to request termination of a representative that exists or was created for a member.

ID: 8072A (W1215)

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