Horizon NJ Health is part of the Horizon Blue Cross Blue Shield of New Jersey enterprise, an independent licensee of the Blue Cross
and Blue Shield Association. ? 2016 Horizon Blue Cross Blue Shield of New Jersey. Three Penn Plaza East, Newark, NJ 07105

ANCM0143

Request for Personal Representative


Instructions: To request a personal representative, please complete the information below, sign in the space provided and return to:
Horizon NJ Health, Member Services, Attention: HIPAA Team, 210 Silvia Street, West Trenton, New Jersey 08628. A separate form is required for each member on the policy or coverage, as applicable. Please print legibly.


Member Information: (circle whether request is for subscriber or dependent) Name (Subscriber/Dependent): _________________________________________________________________________ Policy Identi?ication #: _______________________________________________________________________________ Date of Birth: ________/____________/____________ Telephone #: _________________________________________ Address: _________________________________________________________________________________________ City: ______________________________________________________ State: _______________ Zip: ______________ I, __________________________________________, hereby appoint ___________________________________ to be (member) (personal representative) designated as my personal representative. I understand this request applies to communications from Horizon 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.

Time Period for Representation: From: _______/_______/________ To: _______/_______/________
NOTE: If no time period is provided, this request will remain in effect until the member or his/her legal
representative noti?ies Horizon in writing requesting a change.

Purpose of Representation: (select one) ____ Account Inquiries Only: This means that Horizon is allowed to disclose private information to the individual selected. This individual would have access to information such as: claims, enrollment, premiums, appeals, etc. ____ Correspondence & Account Inquiries: Not only can Horizon disclose private information to the individual selected, but he/she will receive all correspondence that would normally go to the member, including EOBs, checks, etc. For that reason, this option should ONLY be chosen if the member is sure he/she no longer wants to receive relevant coverage information directly, since the personal representative will receive it instead (generally, only in circumstances of incapacity or incompetence (adults), or in the representation of a child; typically not for spouse-to-spouse representation).

Personal Representative Information: (required for privacy veri?ication purposes)
Name (Last, First, MI): ______________________________________________________________________________ Social Security # (Last 4 Digits only): ___________________________ Date of Birth: ________/__________/________ Address: _________________________________________________________________________________________ City: ______________________________________________________ State: _______________ Zip: ______________ Telephone #: ______________________________ Relationship to the member: _______________________________

NOTE: If the representative is court-ordered or has another legal designation (examples: power of attorney, living will, executor or administrator of probate estate), you must attach/include copy of the of?icial document(s) if not already provided. If you are a documented legal representative, you may make this Request and sign this form below on behalf of the member.
Signature of Member / Requestor: _____________________________________________Date: ____/______/______ (circle whether member or other requestor)
Printed Name: ____________________________________________________________________________________



Three Penn Plaza East
Newark, NJ 07105-2200
HorizonBlue.com



CMC0008179_A (0817)


An Independent Licensee of the
Blue Cross and Blue Shield Association.


Notice of Nondiscrimination

Horizon Blue Cross Blue Shield of New Jersey complies with applicable Federal civil rights laws
and does not discriminate against nor does it exclude people or treat them differently on the basis
of race, color, gender, national origin, age, disability, pregnancy, gender identity, sex, sexual
orientation or health status in the administration of the plan, including enrollment and benefit
determinations.

Horizon BCBSNJ provides free aids and services to people with disabilities to communicate
effectively with us, such as qualified sign language interpreters and information written in other
languages.

Contacting Member Services
Please call Member Services at 1-800-355-BLUE (2583) (TTY/TDD 711) or the phone
number on the back of your member ID card, if you need the free aids and services noted
above and for all other Member Services issues, including:

? Claim, benefits or enrollment inquiries
? Lost/stolen ID cards
? Address changes
? Any other inquiry related to your benefits or health plan


Filing a Section 1557 Grievance
If you believe that Horizon BCBSNJ has failed to provide the free communication aids and
services or discriminated on the basis of race, color, gender, national origin, age or disability you
can file a discrimination complaint also known as a Section 1557 Grievance. Horizon BCBSNJ?s
Civil Rights Coordinator can be reached by calling the Member Services number on the back of
your member ID card or by writing to the following address:


Horizon BCBSNJ ? Civil Rights Coordinator
PO Box 820
Newark, NJ 07101


You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

Office for Civil Rights Headquarters
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019 or 1-800-537-7697 (TDD)

OCR Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.








CMC0007942 (0516)

An Independent Licensee of the
Blue Cross and Blue Shield Association.

If you need help understanding this Horizon Blue Cross Blue Shield of New Jersey information,

you have the right to get help in your language at no cost to you. To talk to an interpreter, please

call 1-800-355-BLUE (2583) during normal business hours.



Spanish (Espa?ol): Si necesita ayuda para comprender esta informaci?n de Horizon Blue Cross

Blue Shield of New Jersey, usted tiene el derecho de obtener ayuda en su idioma sin costo

alguno. Para hablar con un int?rprete, s?rvase llamar al 1-855-477-AZUL (2985) durante el

horario normal de trabajo.



Chinese (??)????????????????????????? (Horizon
Blue Cross Blue Shield of New Jersey)?????????????????????
???????????????? 1-800-355-BLUE (2583)?


Korean (???): ???? Horizon Blue Cross Blue Shield of New Jersey? ?? ???
???? ?? ?? ???? ??? ??? ??? ?? ??? ????. ????
??? ???? ?? ?? ?? ??? 1-800-355-BLUE (2583)? ??? ????.


Portuguese (Portugu?s): Se precisar de ajuda para entender estas informa??es da Horizon

Blue Cross Blue Shield of New Jersey, voc? tem o direito de receber gratuitamente assist?ncia no

seu idioma. Para falar com um int?rprete, ligue para: 1-800-355-BLUE (2583) no hor?rio normal

de trabalho.



Gujarati ( ):

, ,

1-800-355-BLUE (2583)



Polish (Polski): Je?eli potrzebujesz pomocy, aby zrozumie? informacje planu Horizon
Blue Cross Blue Shield of New Jersey, masz prawo poprosi? o bezp?atn? pomoc w j?zyku
ojczystym. Aby skorzysta? z pomocy t?umacza, zadzwo? pod numer 1-800-355-BLUE (2583)
podczas normalnych godzin pracy.



Italian (Italiano): Se vi serve aiuto per capire queste informazioni della Horizon Blue Cross

Blue Shield of New Jersey, avete diritto ad assistenza gratis nella vostra lingua. Per parlare con

un interprete, siete pregati di telefonare al numero 1-800-355-BLUE (2583) durante le normali

ore d?ufficio.


Tagalog (Tagalog): Kung kailangan mo ng tulong sa pag-unawa nitong impormasyon ng Horizon

Blue Cross Blue Shield of New Jersey, may karapatan kang humingi ng tulong sa iyong wika

nang walang gastos sa iyo. Upang makipag-usap sa isang taga-interpret, mangyaring tumawag sa

1-800-355-BLUE (2583) sa loob ng karaniwang mga oras ng negosyo.





Russian (??????? ????): ???? ??? ?????????? ?????? ? ??????????? ???? ??????????,
??????????????? ????????? Horizon Blue Cross Blue Shield of New Jersey, ? ??? ???? ?????
?? ????????? ?????? ?? ????? ?????? ????? ?????????. ??? ????? ? ????????????
??????? ?? ?????? ???????? 1-800-355-BLUE (2583) ? ??????? ??????? ????.


Haitian Creole (Krey?l ayisyen): Si ou bezwen ?d pou konprann enf?masyon sou Horizon

Blue Cross Blue Shield of New Jersey, ou gen dwa pou jwenn ?d nan lang natifnatal ou

gratis. Pou pale av?k yon ent?pr?t, tanpri rele nimewo 1-800-355-BLUE (2583) pandan l? n?mal

biznis.



Hindi ( ):

1-800-355-BLUE (2583)



Vietnamese (Ti?ng Vi?t): N?u c?n ???c gi?p ?? ?? hi?u r? th?ng tin n?y c?a Horizon
Blue Cross Blue Shield of New Jersey, qu? v? c? quy?n ???c gi?p ?? b?ng ng?n ng? c?a m?nh
mi?n ph?. Xin g?i s? 1-800-355-BLUE (2583) trong gi? l?m vi?c ?? n?i chuy?n v?i ng??i
th?ng d?ch.


French (Fran?ais): Si vous avez besoin d?assistance pour comprendre ces informations au sujet de
Horizon Blue Cross Blue Shield of New Jersey, vous avez le droit d?obtenir de l?aide dans votre
langue, sans aucun frais. Pour parler avec un interpr?te, veuillez appeler le 1-800-355-BLUE (2583)

pendant les heures normales de bureau.



Navajo (Din?): D77 New Jersey bi[ hahoodzo Horizon Blue Cross Blue Shield, t?11 ninizaad
k?ehj7 baa hane?77 bik?i diit88h bee shik1? a?doowo[ n7n7zingo 47 bee n1?ahoot?i? d00 doo b33h 7l7n7
da. Ata? halne?4 [a? bich?8? hadeesdzih n7n7zingo t?11 sh--d7 1-800-355-BLUE (2583)j8?
nida?anishgo oolki[77 bik?ehgo hod77lnih.


ArabicHorizon Blue Cross Blue Shield of New Jersey

1-800-355-BLUE (2583)



Urdu)(

1-800-355-BLUE (2583)


ANCM0143PersonalRepEnglish.pdf
Binder1.pdf
Nondiscrimination Notice_CMC8179A_FINAL_8.3.17.pdf
CMC7942_Language Mandate Flyer_Taglines FINAL 8.3.17.pdf