Request for Appointment of Legal Personal Representative for Member
Member’s Infor
m
a
tion
Use this form to let another person handle your health care needs which includes allowing full access to your
personal health information, changes to your health care coverage, as well as receiving your health care mail. Read
instructions on PAGE 2 before completing this form. ALL FIELDS MUST BE COMPLETED.
A separate form is required for each member
on the policy. Please print legibly, except where signature is required.
Please complete the information below, sign in the space provided and return to: Horizon Blue Cross Blue Shield of New
Jersey, Attn: HIPAA Team, P.O. Box 1458, Newark, New Jersey 07101-1458 or via fax at 973-274-2358.
Name (
�
Subscriber
�Dependent):
/ /
MM DD YYYY
Telephone #: - -
Date of
Birth:
Address
(on
file):
City:
I, , h
ereby designate
(member)
(legal personal representative)
as my legal personal representative as it relates to communications from Horizo
n BCBSNJ and its business
associates about my private information. I also understand that mental health and/or substance abuse private
information may be disclosed, if I have utilized such services.
Documentation of Legal Authority to Act on Member’s Behalf
(must s
ubmit at least one of the documents listed below)
•
Power of attorney for health care, court order, guardianship, or conservatorship
•
Health care proxy (a document that legally allows
another person to act on your behalf for health care decisions)
•
Executor or administrator of deceased member’s estate
•
Other–Describe the nature of your legal authority to make decisions concerning the member’s health care
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____
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_____________________________________________________________________________________
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_________________________________________________________________________________________________
Please
attach
the
appropriate document(s) to the form.
State:
ZIP:
Legal Personal Representative Information
(required for privacy verification purposes)
Last 4 Digits o
f Social
Security #: Date of Birth:
/ /
MM DD YYYY
Address:
City: State: ZIP:
Telephone #:
- -
Relationship to the member:
Note: All future correspondence such as EOB’s, payment information, etc. will be sent to the Legal Personal
Representative but will still be issued under the member’s name.
Time Period for Representation: From: _____
/ _____ / ________ To: _____ / _____ / ________
MM DD YYYY MM DD YYYY
NOTE: If no time period is provided, this request will remain in effect until the member or his/her legal personal
representative notifies Horizon BCBSNJ in writing requesting a change or until the expiration date on the attached
legal document.
Check here if you want your resp
onse to this request sent via email.
Email address:
Date: /
/
Signature of
Member
Requestor:
(check whether member or other requestor)
MM DD YYYY
Printed Name:
3242
6 (0219)
An independent licensee of the Blue Cross and Blue Shield Association.
This form applies to all Horizon BCBSNJ-issued products.
Subscriber Identification #:
Name (Last, First, MI):
Gender: M F Undisclosed
click to sign
signature
click to edit
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