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DESIGNATED AUTHORIZED REPRESENTATIVE (DAR) FOR ADULTS

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REQUEST FORM

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

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

Use this form to request permission to get access or give someone else access to the member’s electronic health information through MyNJFCHealthData.

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

I , , have the authority by law to act as the Legal Representative for the aforementioned member for the sole purpose of assigning a DAR who will have access to the member’s electronic health information (EHI).  

NOTE: If the representative is court-ordered or has another legal designation (examples: power of attorney, guardian), you must provide a copy of the document(s). If you are a documented legal representative, you may make this Request and sign this form below on behalf of the member. 

• I understand that at any time, I can take back or cancel my permission for the DAR to view the member’s information.  
• I understand that I must use the approved DAR Revocation form to take back my permission. 
• I understand that any information that was viewed or shared by the DAR 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:

• I attest that I have the authority to represent the member as his/her Legal Representative.
• As the DAR, I understand that I will have access to the electronic health information of the member, including claims information relating to the medical, pharmacy, dental, vision, mental health, substance abuse, HIV/AIDS, psychotherapy, reproductive, communicable disease and health care program information.
• I am aware that if I re-disclose the member’s electronic health information, the information may no longer be protected by federal and State privacy laws and regulations.
• I certify that I will, at all times, maintain the confidentiality of any information regarding the member.
• 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 the member’s electronic health information from MyNJFCHealthData.

• I understand that at any time, I can take back or cancel my permission for the DAR to view my information.  
• I understand that I must use the approved DAR Revocation form to take back my permission. 
• I understand that any information that was viewed or shared by my DAR 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;
• Certify that I have chosen the person to be my Designated Authorized Representative for me and that I understand that I am granting complete access to my electronic health information;
• 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 Designated Authorized Representative; 
• Am aware my health information may be subject to re-disclosure by my Designated Authorized Representative, and if my 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
• 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.

I certify that I will at all times maintain the confidentiality of any information regarding the member. 

By my signature below, I:

• I attest that I have the authority to represent the member as his/her Legal Representative.
• I certify that I have chosen the person, above, to be the designated authorized representative of the member and that I understand that I am granting that person complete access to the member’s 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 the designated authorized representative.
• I am aware that the member’s electronic health information may be subject to re-disclosure by the designated authorized representative and if the 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.
• I certify that I will, at all times, maintain the confidentiality of the member.
• 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 the member’s electronic health information from MyNJFCHealthData.