Request for Appointment of Limited Personal Representative for Member
s form if you wish to allow your personal health information to be disclosed to the person named below so they can
assist you with your health care and payment for health care. This person will not be permitted to make policy changes.
tructions on PAGE 3 before completing this form. ALL FIELDS MUST BE COMPLETED.
olicy. 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. This form is also available for online submission via Horizon BCBSNJ
Member Portal at HorizonBlue.com
as my limited personal representative. I understand this
request applies to communications from Horizon BCBSNJ
and its business associates about my private information.
Information that Horizon BCBSNJ may disclose:
I authorize Horizon BCBSNJ to disclose the
following information to my limited personal representative:
Option 1: All my information, including potentially sensitive information. This may include a
illness or condition),
(type of treatment),
claims, the name of my doctors
other health care providers
(like billing and banking). Horizon is permitted to disclose information related to HIV or AIDS,
sexually transmitted disease, mental or behavioral health, substance use disorders (including alcohol abuse), genetic
information, and sexual health (family planning & contraception, abortion, and pregnancy).
Please note for certain behavioral health disclosures you may be required to provide additional authorizations.
2: All my information, BUT NOT sensitive information. Horizon is NOT permitted to disclose sensitive
information, which may include a diagnosis (name of illness or condition), procedure (type of treatment), or
claims payment message that relates to HIV or AIDS, sexually transmitted disease, mental or behavioral health,
substance use disorders (including alcohol abuse), genetic information, and sexual health (family planning &
contraception, abortion, and pregnancy). Please be advised that Horizon will disclose the name of your doctors
and other health care providers, which may be an indication of a sensitive service, to your Limited Personal
Name (�Subscriber �Dependent):
Subscriber Identification #:
MM DD YYYY
Telephone #: - -
Date of Birth:
Address (on file):
I, , hereby designate
(limited personal representative)
An independent licensee of the Blue Cross and Blue Shield Association.
This form applies to all Horizon BCBSNJ-issued products.