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Forms & Documents

Appointment of a Representative

An enrollee may have a representative who is either appointed by the enrollee or authorized under State or other applicable law to act on behalf of the enrollee in filing a grievance, requesting a coverage determination, or in dealing with any of the levels of the appeals process. Horizon BCBSNJ will comply with regulatory requirements for ensuring that individuals who represent enrollees are either appointed or authorized as representatives by requiring the submission of a CMS approved Appointment of Representative Form. The CMS form with instructions can found at CMS 1696 | CMS.

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