Revocation of MyNJFCHealthData Designated Authorized Representative (DAR)

Use this form to revoke (take back) permission to get or to view electronic health information from MyNJFCHealthData.

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

Who is completing this form? Please select one of the options below

Member

Member's Legal Representative

Member Information

*Represents required field

Last Name

First Name

Address

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

Telephone

Email

Confirm Email

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.

I revoke permission for NJ FamilyCare to share my electronic health information with:

Full Name of MyNJFCHealthData DAR

Last Name

First Name

Address

Telephone

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

Email

Confirm Email

By signing below, I understand and agree that:

This revocation is voluntary.
Revocation is effective on the date my request is processed. (Please allow up to 15 calendar days for processing).

Member's Legal Representative Information

Note: If you are signing on behalf of a Member, please complete the following section.

Last Name

First Name

Relationship to member Value is not selected

Other - Specify the relationship

Address

Telephone

Email

Confirm Email

Is the MyNJFCHealthData Designated Authorized Representative (DAR) the same as the Member’s Legal Representative?

Yes

No

MyNJFCHealthData Designated Authorized Representative's Information

Last Name

First Name

Address

Telephone

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

Email

Confirm Email

Relationship of MyNJFCHealthData DAR to Member Value is not selected

Other - Specify the relationship

By signing below, I understand and agree that:

This revocation is voluntary.
Revocation is effective on the date my request is processed. (Please allow up to 15 calendar days for processing).

Signature of Member

Signature of Legal Representative

Date

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DHS-DMAHS-003.MyNJFCHealthData DAR Revocation Form

Revocation of MyNJFCHealthData Designated Authorized Representative (DAR)

Member Information

Full Name of MyNJFCHealthData DAR

Member's Legal Representative Information

MyNJFCHealthData Designated Authorized Representative's Information