MyNJFCHealthData Designated Authorized Representative (DAR)

For Adults (No Diminished Mental Capacity)

REQUEST FORM

Use this form to request permission to give someone access to your electronic health information through MyNJFCHealthData.

PRIVACY WARNING: Information entered in the fields will remain in the form until the form is submitted or the browser window is closed. To ensure the privacy of your information, either close your browser window or use the “Clear Form” button if you are not ready to submit your form. The “Clear Form” button will clear all field entries.

Several resources to help complete this MyNJFCHealthData DAR Request Form are available here and can answer most frequently asked questions.

Member Information

Items with * are required

Last Name

First Name

Date of Birth Note: Only a DOB 18 years of age or older will be accepted.

Address

Country Code Value is not selected

Telephone #

Telephone # Please specify country code

Email Address

Confirm Email Address

Control Card Number (CCN) (If known)

Choose and enter your unique 6-digit PIN below: Note: Keep your PIN in a safe place. You will need to use your PIN if you are contacted by the MyNJFCHealthData Team for more information.

MyNJFCHealthData Designated Authorized Representative (DAR) Information

Last Name

First Name

Date of Birth Note: Only a DOB 18 years of age or older will be accepted.

Address

Country Code Value is not selected

Telephone (#)

Telephone (#) Please specify country code

Email

Confirm Email

Relationship Value is not selected

Other - Specify the relationship

START DATE - I would like the start date to be

END DATE – I understand that the end date will be one (1) year from the Start Date unless I choose an earlier date.

Check here if you want to choose an earlier end date. (Uncheck this box if you want to return to the 1 year end date)

END DATE - Please pick an earlier end date.

DateHidden End Date Calculations

I confirm the following:

I understand that at any time, I can take back or cancel my permission for the MyNJFCHealthData Designated Authorized Representative to view my information.
I understand that I must use the approved MyNJFCHealthData Designated Authorized Representative Revocation Form to take back my permission.
I understand that any information that was viewed or shared by my MyNJFCHealthData Designated Authorized Representative before I cancelled my permission cannot be taken back.
Cancellation of my permission is effective on the date my request is processed, which can take up to 15 calendar days.

By my signature below:

I attest that my decision to designate an Authorized Representative is voluntary and made freely;
I certify that I have chosen the person to be my MyNJFCHealthData Designated Authorized Representative for me and that I understand that I am granting complete access to my electronic health information;
I fully understand that certain sensitive claims information, including information relating to medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease and health care program information, may be disclosed to my MyNJFCHealthData Designated Authorized Representative;
I am aware my health information may be subject to re-disclosure by my MyNJFCHealthData Designated Authorized Representative, and if my MyNJFCHealthData Designated Authorized Representative is not a health plan or health care provider, the information may no longer be protected by Federal and state privacy laws and regulations; and
I agree to release and hold harmless the State of New Jersey, the NJ Department of Human Services, the Division of Medical Assistance and Health Services and its employees and contractors; the New Jersey Institute of Technology; the New Jersey Innovation Institute and; Velatura, from any and all claims related to the use and disclosure of my electronic health information from MyNJFCHealthData.

Signature of Member

Date

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DHS-DMAHS-001.MyNJFCHealthData DAR No Diminished Form

Member Information

MyNJFCHealthData Designated Authorized Representative (DAR) Information