VERY IMPORTANT NOTICE FOR CAREGIVERS:

For You to Have a Say in Your Loved One’s Care

Horizon NJ Health knows how important you are as a caregiver. However, there are laws that protect the privacy of our members and their personal medical and insurance information. The Health Insurance Portability and Accountability Act (HIPAA) is one of these laws. It says that no health care provider or company can share a patient’s information without the patient’s written consent. This applies to your loved one when he or she becomes a member of Horizon NJ Health.

Horizon NJ Health has a form that gives you permission to see or discuss your loved one’s member information that we keep. The form is called Request for Personal Representative. The signed form is your loved one’s permission to discuss your care and information with us.

• If your loved one does not make you his or her Personal Representative, and
• You have no legal documents that give you access to his or her health information,

Horizon NJ Health cannot discuss any care information with you.

If you become a Personal Representative, it does not take away any of your loved one’s rights or responsibilities related to his or her care. It does allow you to ask questions and provide information that helps us deliver the care that’s needed.

How to complete the Request for Personal Representative form

1. Your loved one should fill out this form in ink, starting with Member Information at the top. (You can help if your loved one cannot do this by him- or herself.) If your loved one wants you to be the personal representative, your name should be entered above the blank with “personal representative” underneath.
2. The dates during which you are the personal representative should be written in the Time Period for Representation blanks. If this area is empty, you will stay on as the Personal Representative unless you or your loved one asks for a change.
3. Under Purpose of Representation, your loved one will tell us how to share his or her Horizon NJ Health information with you. If neither option is checked or has an “X” next to it, we cannot share your loved one’s information with you at all.
   • a. Account Inquiries Only means that your loved one gives you permission to see or discuss important information about claims, enrollment, care, premium payments etc. You can also talk to any Horizon NJ Health representative for help or clarification about your loved one’s care.
   • b. Correspondence & Account Inquiries means that your loved one gives you permission to receive and handle all paperwork and information regarding his or her care – information that your loved one would ordinarily receive. (This permission is usually given if your loved one, our member, is a minor or is unable to make decisions; for example, if he or she has Alzheimer’s disease.)
   • c. Complete the Personal Representative Information, providing any of the legal documents mentioned. Your loved one, the member, must sign at the bottom.
4. You can give the completed form to a Care Manager or send it to:
   Horizon NJ Health Member Services
   Attention: HIPAA Team
   210 Silvia Street
   West Trenton, NJ 08628

Personal Representative Information Form