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        • BlueNotes Issue 1 2021BlueNotes Issue 1 2021
          • BlueNotes Issue 1 2021
          • Your annual wellness exam: a key part of staying healthyYour annual wellness exam: a key part of staying healthy
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          • Our commitment to qualityOur commitment to quality
          • Horizon Neighbors in Health: Education WorksHorizon Neighbors in Health: Education Works
          • Member rights and responsibilitiesMember rights and responsibilities
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          • Coming soon: the Horizon NJ Health AppComing soon: the Horizon NJ Health App
          • 5 ways to prevent falls5 ways to prevent falls
          • Follow-up care after an ER visitFollow-up care after an ER visit
          • Are you at risk for aspiration pneumonia?Are you at risk for aspiration pneumonia?
          • New name, same service: LogistiCare is now ModivCareNew name, same service: LogistiCare is now ModivCare
          • Having a baby? You have a new benefit: Doula servicesHaving a baby? You have a new benefit: Doula services
          • We can help you quit smoking or vapingWe can help you quit smoking or vaping
          • You may be eligible for Horizon NJ TotalCare (HMO D-SNP)You may be eligible for Horizon NJ TotalCare (HMO D-SNP)
          • When is Urgent Care the right choice?When is Urgent Care the right choice?
          • COVID-19 vaccine updateCOVID-19 vaccine update
          • Changes to covered medicinesChanges to covered medicines
          • New genericsNew generics
          • First aid for seizuresFirst aid for seizures
      • MLTSS Member NewslettersMLTSS Member Newsletters
        • MLTSS Member Newsletters
        • CareNotes Issue 1 2021CareNotes Issue 1 2021
          • CareNotes Issue 1 2021
          • 5 tips to get the most from your plan5 tips to get the most from your plan
          • First aid for seizuresFirst aid for seizures
          • Your annual wellness exam: a key part of staying healthyYour annual wellness exam: a key part of staying healthy
          • Our commitment to qualityOur commitment to quality
          • Do you have an advance directive?Do you have an advance directive?
          • Coming soon: the Horizon NJ Health AppComing soon: the Horizon NJ Health App
          • Important information for members with behavioral health conditionsImportant information for members with behavioral health conditions
          • Our Member Advocates are here for youOur Member Advocates are here for you
          • 5 ways to prevent falls5 ways to prevent falls
          • You may be eligible for Horizon NJ TotalCare (HMO D-SNP)You may be eligible for Horizon NJ TotalCare (HMO D-SNP)
          • When is Urgent Care the right choice?When is Urgent Care the right choice?
          • Follow-up care after an ER visitFollow-up care after an ER visit
          • Are you at risk for aspiration pneumonia?Are you at risk for aspiration pneumonia?
          • New name, same service: LogistiCare is now ModivCareNew name, same service: LogistiCare is now ModivCare
          • 5 ways to keep your eyes healthy5 ways to keep your eyes healthy
          • Member rights and responsibilitiesMember rights and responsibilities
          • We can help you quit smoking or vapingWe can help you quit smoking or vaping
          • COVID-19 vaccine updateCOVID-19 vaccine update
          • Changes to covered medicinesChanges to covered medicines
          • New genericsNew generics
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      • How Much Do You Know about Lead Poisoning?How Much Do You Know about Lead Poisoning?
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        • We will remind you about your health screeningsWe will remind you about your health screenings
      • Mom's GEMS Prenatal ProgramMom's GEMS Prenatal Program
        • Mom's GEMS Prenatal Program
        • Enroll in Mom’s GEMSEnroll in Mom’s GEMS
      • A Health and Wellness Program for ChildrenA Health and Wellness Program for Children
        • A Health and Wellness Program for Children
        • What to Expect during your Child’s Wellness Checkups Quick Reference GuideWhat to Expect during your Child’s Wellness Checkups Quick Reference Guide
        • What is Child Development?What is Child Development?
        • Guidelines for Key Developmental MilestonesGuidelines for Key Developmental Milestones
        • Screening Tests: Frequently Asked QuestionsScreening Tests: Frequently Asked Questions
      • Staying Healthy As You AgeStaying Healthy As You Age
        • Staying Healthy As You Age
        • Depression in Older Adults and the ElderlyDepression in Older Adults and the Elderly
      • Quit Smoking SupportQuit Smoking Support
      • Lifeline Assistance Program: Free Cell PhoneLifeline Assistance Program: Free Cell Phone
      • Take 5 If You Have DiabetesTake 5 If You Have Diabetes
      • Care ManagementCare Management
      • Diabetes and Kidney DiseaseDiabetes and Kidney Disease
      • Horizon Neighbors in HealthHorizon Neighbors in Health
      • Quality Improvement ProgramQuality Improvement Program
      • Self Direction – Personal Preference Program (PPP)Self Direction – Personal Preference Program (PPP)
    • Horizon NJ Health VideosHorizon NJ Health Videos
    • Appointment Assistance Request FormAppointment Assistance Request Form
    • Grievance FormGrievance Form
    • How do I Renew?How do I Renew?
    • Updates and AnnouncementsUpdates and Announcements
      • Updates and Announcements
      • Recall of Artificial Tears 10 mg/mL Lubricant Eye DropsRecall of Artificial Tears 10 mg/mL Lubricant Eye Drops
      • Recall of Artificial Tears 10 mg/mL Lubricant Eye DropsRecall of Artificial Tears 10 mg/mL Lubricant Eye Drops
      • Changes for COVID-19 Testing: Stay In-NetworkChanges for COVID-19 Testing: Stay In-Network
      • Retiro del mercado de Piperacillin y Tazobactam para inyección, USP, 3.375 gramos por vialRetiro del mercado de Piperacillin y Tazobactam para inyección, USP, 3.375 gramos por vial
      • Recall of Atovaquone Oral Suspension 750mg/5mLRecall of Atovaquone Oral Suspension 750mg/5mL
      • Recall of TIROSINT SOL (levothyroxine sodium) Oral SolutionRecall of TIROSINT SOL (levothyroxine sodium) Oral Solution
      • How a Community Doula Can Help During PregnancyHow a Community Doula Can Help During Pregnancy
      • Recall of Sodium Bicarbonate Injection, USP, 8.4%, 50 mEq/50 mL VialRecall of Sodium Bicarbonate Injection, USP, 8.4%, 50 mEq/50 mL Vial
      • Save on Internet Services With the Affordable Connectivity ProgramSave on Internet Services With the Affordable Connectivity Program
      • We've Got Your Monkeypox Concerns CoveredWe've Got Your Monkeypox Concerns Covered
      • Autism Services AnnouncementAutism Services Announcement
      • Recall of Milk of Magnesia 2400 mg/30 mL Oral SuspensionRecall of Milk of Magnesia 2400 mg/30 mL Oral Suspension
      • Recall of Humalog KwikPen U-100Recall of Humalog KwikPen U-100
      • Recall of Magnesium Hydroxide 1200 mg/Aluminum Hydroxide 1200 mg/Simethicone 120 mg per 30 mLRecall of Magnesium Hydroxide 1200 mg/Aluminum Hydroxide 1200 mg/Simethicone 120 mg per 30 mL
      • Recall of Symjepi (epinephrine) Injection 0.15 mg (0.15 mg/0.3 mL) and 0.3 mg (0.3 mg/0.3 mL) Pre-Filled Single-Dose SyringesRecall of Symjepi (epinephrine) Injection 0.15 mg (0.15 mg/0.3 mL) and 0.3 mg (0.3 mg/0.3 mL) Pre-Filled Single-Dose Syringes
      • Need Help With Your Utility Bills?Need Help With Your Utility Bills?
      • Recall of Senna Syrup 8.8mg/5mLRecall of Senna Syrup 8.8mg/5mL
      • At-Home COVID-19 TestingAt-Home COVID-19 Testing
      • Recall of Enoxaparin Sodium Injection, 40mg/0.4mLRecall of Enoxaparin Sodium Injection, 40mg/0.4mL
      • Recall of Lidocaine HCl Topical Solution 4%Recall of Lidocaine HCl Topical Solution 4%
      • Recall of Glucagon Emergency Kit for Low Blood SugarRecall of Glucagon Emergency Kit for Low Blood Sugar
      • Recall of Firvanq Oral Solution 50mg/mL KitRecall of Firvanq Oral Solution 50mg/mL Kit
      • Recall of Chantix TabletsRecall of Chantix Tablets
      • Recall of Lidocaine HCl Topical Solution 4%Recall of Lidocaine HCl Topical Solution 4%
      • Recall of Atovaquone Oral Suspension 750mg/5mLRecall of Atovaquone Oral Suspension 750mg/5mL
      • New Behavioral Health Benefit: Care Management ServicesNew Behavioral Health Benefit: Care Management Services
      • Interoperability SupportInteroperability Support
      • New benefit for members: Doula servicesNew benefit for members: Doula services
      • LogistiCare is now ModivcareLogistiCare is now Modivcare
      • COVID-19 vaccines available in Essex CountyCOVID-19 vaccines available in Essex County
      • Preventive Health: Medicaid UpdatePreventive Health: Medicaid Update
      • Recall of NP Thyroid TabletsRecall of NP Thyroid Tablets
      • NJ Residents can get opioid-overdose antidote naloxone at no cost from September 24 to 26NJ Residents can get opioid-overdose antidote naloxone at no cost from September 24 to 26
      • Recall of DDAVP® Nasal Spray 10 mcg/0.1mL, Desmopressin Acetate Nasal Spray 10 mcg/0.1mL, STIMATE® Nasal Spray 1.5 mg/mLRecall of DDAVP® Nasal Spray 10 mcg/0.1mL, Desmopressin Acetate Nasal Spray 10 mcg/0.1mL, STIMATE® Nasal Spray 1.5 mg/mL
      • Recall of Daptomycin for Injection, 500 mg/vialRecall of Daptomycin for Injection, 500 mg/vial
      • DIR Services for children diagnosed with Autism Spectrum DisorderDIR Services for children diagnosed with Autism Spectrum Disorder
      • New benefit: Peer Recovery Support ServicesNew benefit: Peer Recovery Support Services
      • Taking care of your mental health during and after pregnancyTaking care of your mental health during and after pregnancy
      • What You Need to Know About COVID-19What You Need to Know About COVID-19
      • Changes to Management of the Horizon Behavioral Health ProgramChanges to Management of the Horizon Behavioral Health Program
      • Recall of Metformin Hydrochloride Extended Release Tablets, 500mg and 750mgRecall of Metformin Hydrochloride Extended Release Tablets, 500mg and 750mg
      • Recall of NP Thyroid TabletsRecall of NP Thyroid Tablets
      • Recall of Metformin Hydrochloride Extended Release Tablets, 500mgRecall of Metformin Hydrochloride Extended Release Tablets, 500mg
      • A message from the State of New Jersey Department of Human Services: How NJ FamilyCare is working to support New Jerseyans’ health care needs during the Coronavirus emergencyA message from the State of New Jersey Department of Human Services: How NJ FamilyCare is working to support New Jerseyans’ health care needs during the Coronavirus emergency
      • Coronavirus resourcesCoronavirus resources
      • Referrals no longer needed!Referrals no longer needed!
      • Services for children diagnosed with Autism Spectrum DisorderServices for children diagnosed with Autism Spectrum Disorder
      • 3 ways to get care3 ways to get care
      • Removal of Ranitidine from the marketRemoval of Ranitidine from the market
      • Teledentistry is now availableTeledentistry is now available
      • Attention: Manufacturer recall of Phenytoin SuspensionAttention: Manufacturer recall of Phenytoin Suspension
      • Language translator servicesLanguage translator services
      • Attention Members: Manufacturer recall of Lamotrigine 100 mg tabletsAttention Members: Manufacturer recall of Lamotrigine 100 mg tablets
      • Atención a los miembros: Retiro del fabricante de comprimidos, cápsulas y jarabes de ranitidineAtención a los miembros: Retiro del fabricante de comprimidos, cápsulas y jarabes de ranitidine
      • Attention Members: Manufacturer recall of Ranitidine Tablets, Capsules and SyrupAttention Members: Manufacturer recall of Ranitidine Tablets, Capsules and Syrup
      • ¿Busca maneras de retribuir en esta época de fiestas?¿Busca maneras de retribuir en esta época de fiestas?
      • Looking for ways to give back this holiday season?Looking for ways to give back this holiday season?
      • Atención miembros: Retiro del fabricante de comprimidos y cápsulas de ranitidinaAtención miembros: Retiro del fabricante de comprimidos y cápsulas de ranitidina
      • Attention Members: Manufacturer recall of Ranitidine Tablets & CapsulesAttention Members: Manufacturer recall of Ranitidine Tablets & Capsules
      • Important Information for SNAP Recipients about your February BenefitsImportant Information for SNAP Recipients about your February Benefits
      • A message from Human Services Commissioner Johnson: Fighting Lead with NutritionA message from Human Services Commissioner Johnson: Fighting Lead with Nutrition
      • Attention Members: Manufacturer recall of Natpara for InjectionAttention Members: Manufacturer recall of Natpara for Injection
      • Recall of Losartan Potassium and Losartan Potassium and Hydrochlorothiazide tabletsRecall of Losartan Potassium and Losartan Potassium and Hydrochlorothiazide tablets
      • Attention Members: Manufacturer recall of Fluorouracil InjectionAttention Members: Manufacturer recall of Fluorouracil Injection
      • Recall of Promacta 12.5mg for Oral SuspensionRecall of Promacta 12.5mg for Oral Suspension
      • Updates to the Internal Appeal processUpdates to the Internal Appeal process
      • Recall of 8.4% Sodium Bicarbonate InjectionRecall of 8.4% Sodium Bicarbonate Injection
      • Organ and tissue donation saves livesOrgan and tissue donation saves lives
      • Recall of Fentanyl Transdermal 12 mcg/h PatchesRecall of Fentanyl Transdermal 12 mcg/h Patches
      • Recall of Ceftriaxone for InjectionRecall of Ceftriaxone for Injection
      • Recall of Losartan Potassium Hydrochlorothiazide TabletsRecall of Losartan Potassium Hydrochlorothiazide Tablets
      • Recall of Losartan Potassium TabletsRecall of Losartan Potassium Tablets
      • Recall of Amlodipine Valsartan Tablets USP, Valsartan HCTZ Tablets USP and Valsartan Tablets USPRecall of Amlodipine Valsartan Tablets USP, Valsartan HCTZ Tablets USP and Valsartan Tablets USP
      • Recall of Valsartan, Amlodipine/Valsartan and Valsartan/Hydrochlorothiazide TabletsRecall of Valsartan, Amlodipine/Valsartan and Valsartan/Hydrochlorothiazide Tablets
      • Treatment for substance use disorders at Long-Term Residential facilitiesTreatment for substance use disorders at Long-Term Residential facilities
      • Important Billing ReminderImportant Billing Reminder
      • Retiro de jeringas precargadas de dosis única de Symjepi (epinefrina) inyectable de 0.15 mg (0.15 mg/0.3 ml) y 0.3 mg (0.3 mg/0.3 ml)Retiro de jeringas precargadas de dosis única de Symjepi (epinefrina) inyectable de 0.15 mg (0.15 mg/0.3 ml) y 0.3 mg (0.3 mg/0.3 ml)
    • NJ Health Privacy Forms-EnglishNJ Health Privacy Forms-English
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      • How to Recognize Abuse?How to Recognize Abuse?
      • How Can I Report Abuse?How Can I Report Abuse?
    • Help for YouHelp for You
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      • Avoid Caregiver BurnoutAvoid Caregiver Burnout
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      • Enjoying Time with a SeniorEnjoying Time with a Senior
      • Is It Just Stress-Or Is It Depression?Is It Just Stress-Or Is It Depression?
      • Easy Tips for Healthy EatingEasy Tips for Healthy Eating
      • Exercise: Keep It FunExercise: Keep It Fun
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  • Resources
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    • How Horizon NJ Health Works
      • Members and Bills
      • Out of Town?
      • Specialists
      • When to Use the Emergency Room
      • Your Primary Care Provider (PCP)
      • Member Rights and Responsibilities
      • Need Medical Transportation?
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      • Medical Necessity Determination
    • What are County Boards of Social Services?
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    • Help Applying for SSI
    • The NJFC Directory of Dentists Treating Children under the Age of 6
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    • Member Newsletters
      • BlueNotes Issue 1 2021
        • Your annual wellness exam: a key part of staying healthy
        • 5 tips to get the most from your plan
        • Our commitment to quality
        • Horizon Neighbors in Health: Education Works
        • Member rights and responsibilities
        • Important information for members with behavioral health conditions
        • Coming soon: the Horizon NJ Health App
        • 5 ways to prevent falls
        • Follow-up care after an ER visit
        • Are you at risk for aspiration pneumonia?
        • New name, same service: LogistiCare is now ModivCare
        • Having a baby? You have a new benefit: Doula services
        • We can help you quit smoking or vaping
        • You may be eligible for Horizon NJ TotalCare (HMO D-SNP)
        • When is Urgent Care the right choice?
        • COVID-19 vaccine update
        • Changes to covered medicines
        • New generics
        • First aid for seizures
    • MLTSS Member Newsletters
      • CareNotes Issue 1 2021
        • 5 tips to get the most from your plan
        • First aid for seizures
        • Your annual wellness exam: a key part of staying healthy
        • Our commitment to quality
        • Do you have an advance directive?
        • Coming soon: the Horizon NJ Health App
        • Important information for members with behavioral health conditions
        • Our Member Advocates are here for you
        • 5 ways to prevent falls
        • You may be eligible for Horizon NJ TotalCare (HMO D-SNP)
        • When is Urgent Care the right choice?
        • Follow-up care after an ER visit
        • Are you at risk for aspiration pneumonia?
        • New name, same service: LogistiCare is now ModivCare
        • 5 ways to keep your eyes healthy
        • Member rights and responsibilities
        • We can help you quit smoking or vaping
        • COVID-19 vaccine update
        • Changes to covered medicines
        • New generics
    • Confidential Communication
    • 24/7 Nurse Line
    • Community Resources
    • How Much Do You Know about Lead Poisoning?
  • Handbooks
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  • Programs
    • Horizon Healthy Journey
      • We will remind you about your health screenings
    • Mom's GEMS Prenatal Program
      • Enroll in Mom’s GEMS
    • A Health and Wellness Program for Children
      • What to Expect during your Child’s Wellness Checkups Quick Reference Guide
      • What is Child Development?
      • Guidelines for Key Developmental Milestones
      • Screening Tests: Frequently Asked Questions
    • Staying Healthy As You Age
      • Depression in Older Adults and the Elderly
    • Quit Smoking Support
    • Lifeline Assistance Program: Free Cell Phone
    • Take 5 If You Have Diabetes
    • Care Management
    • Diabetes and Kidney Disease
    • Horizon Neighbors in Health
    • Quality Improvement Program
    • Self Direction – Personal Preference Program (PPP)
  • Horizon NJ Health Videos
  • Appointment Assistance Request Form
  • Grievance Form
  • How do I Renew?
  • Updates and Announcements
    • Recall of Artificial Tears 10 mg/mL Lubricant Eye Drops
    • Recall of Artificial Tears 10 mg/mL Lubricant Eye Drops
    • Changes for COVID-19 Testing: Stay In-Network
    • Retiro del mercado de Piperacillin y Tazobactam para inyección, USP, 3.375 gramos por vial
    • Recall of Atovaquone Oral Suspension 750mg/5mL
    • Recall of TIROSINT SOL (levothyroxine sodium) Oral Solution
    • How a Community Doula Can Help During Pregnancy
    • Recall of Sodium Bicarbonate Injection, USP, 8.4%, 50 mEq/50 mL Vial
    • Save on Internet Services With the Affordable Connectivity Program
    • We've Got Your Monkeypox Concerns Covered
    • Autism Services Announcement
    • Recall of Milk of Magnesia 2400 mg/30 mL Oral Suspension
    • Recall of Humalog KwikPen U-100
    • Recall of Magnesium Hydroxide 1200 mg/Aluminum Hydroxide 1200 mg/Simethicone 120 mg per 30 mL
    • Recall of Symjepi (epinephrine) Injection 0.15 mg (0.15 mg/0.3 mL) and 0.3 mg (0.3 mg/0.3 mL) Pre-Filled Single-Dose Syringes
    • Need Help With Your Utility Bills?
    • Recall of Senna Syrup 8.8mg/5mL
    • At-Home COVID-19 Testing
    • Recall of Enoxaparin Sodium Injection, 40mg/0.4mL
    • Recall of Lidocaine HCl Topical Solution 4%
    • Recall of Glucagon Emergency Kit for Low Blood Sugar
    • Recall of Firvanq Oral Solution 50mg/mL Kit
    • Recall of Chantix Tablets
    • Recall of Lidocaine HCl Topical Solution 4%
    • Recall of Atovaquone Oral Suspension 750mg/5mL
    • New Behavioral Health Benefit: Care Management Services
    • Interoperability Support
    • New benefit for members: Doula services
    • LogistiCare is now Modivcare
    • COVID-19 vaccines available in Essex County
    • Preventive Health: Medicaid Update
    • Recall of NP Thyroid Tablets
    • NJ Residents can get opioid-overdose antidote naloxone at no cost from September 24 to 26
    • Recall of DDAVP® Nasal Spray 10 mcg/0.1mL, Desmopressin Acetate Nasal Spray 10 mcg/0.1mL, STIMATE® Nasal Spray 1.5 mg/mL
    • Recall of Daptomycin for Injection, 500 mg/vial
    • DIR Services for children diagnosed with Autism Spectrum Disorder
    • New benefit: Peer Recovery Support Services
    • Taking care of your mental health during and after pregnancy
    • What You Need to Know About COVID-19
    • Changes to Management of the Horizon Behavioral Health Program
    • Recall of Metformin Hydrochloride Extended Release Tablets, 500mg and 750mg
    • Recall of NP Thyroid Tablets
    • Recall of Metformin Hydrochloride Extended Release Tablets, 500mg
    • A message from the State of New Jersey Department of Human Services: How NJ FamilyCare is working to support New Jerseyans’ health care needs during the Coronavirus emergency
    • Coronavirus resources
    • Referrals no longer needed!
    • Services for children diagnosed with Autism Spectrum Disorder
    • 3 ways to get care
    • Removal of Ranitidine from the market
    • Teledentistry is now available
    • Attention: Manufacturer recall of Phenytoin Suspension
    • Language translator services
    • Attention Members: Manufacturer recall of Lamotrigine 100 mg tablets
    • Atención a los miembros: Retiro del fabricante de comprimidos, cápsulas y jarabes de ranitidine
    • Attention Members: Manufacturer recall of Ranitidine Tablets, Capsules and Syrup
    • ¿Busca maneras de retribuir en esta época de fiestas?
    • Looking for ways to give back this holiday season?
    • Atención miembros: Retiro del fabricante de comprimidos y cápsulas de ranitidina
    • Attention Members: Manufacturer recall of Ranitidine Tablets & Capsules
    • Important Information for SNAP Recipients about your February Benefits
    • A message from Human Services Commissioner Johnson: Fighting Lead with Nutrition
    • Attention Members: Manufacturer recall of Natpara for Injection
    • Recall of Losartan Potassium and Losartan Potassium and Hydrochlorothiazide tablets
    • Attention Members: Manufacturer recall of Fluorouracil Injection
    • Recall of Promacta 12.5mg for Oral Suspension
    • Updates to the Internal Appeal process
    • Recall of 8.4% Sodium Bicarbonate Injection
    • Organ and tissue donation saves lives
    • Recall of Fentanyl Transdermal 12 mcg/h Patches
    • Recall of Ceftriaxone for Injection
    • Recall of Losartan Potassium Hydrochlorothiazide Tablets
    • Recall of Losartan Potassium Tablets
    • Recall of Amlodipine Valsartan Tablets USP, Valsartan HCTZ Tablets USP and Valsartan Tablets USP
    • Recall of Valsartan, Amlodipine/Valsartan and Valsartan/Hydrochlorothiazide Tablets
    • Treatment for substance use disorders at Long-Term Residential facilities
    • Important Billing Reminder
    • Retiro de jeringas precargadas de dosis única de Symjepi (epinefrina) inyectable de 0.15 mg (0.15 mg/0.3 ml) y 0.3 mg (0.3 mg/0.3 ml)
  • NJ Health Privacy Forms-English
  • NJ Health Privacy Forms- Spanish
  • COVID-19 Resources
  • Community Doulas

NJ Health Privacy Forms- Spanish

Pdf Image207135_HNJH - Authorization for Disclosure of PHI_Spanish  

Pdf Image207135_HNJH - Confidential Communication_Spanish  

Pdf Image207135_HNJH - Request for Accounting of Disclosure_Spanish  

Pdf Image207135_HNJH - Request for Appointment of Legal Rep_Spanish  

Pdf Image207135_HNJH - Request for Appointment of Limited Rep_Spanish  

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