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Get Ez Blue Authorization Agreement Illinois Form

Gn and return this authorization form. C f submitting by fax, please fax this form to 1-800-625-5916. I f submitting this form by mail, please use this address: I Blue Cross and Blue Shield of Illinois P.O. Box 3236 Naperville, IL 60566-9708 If you have any questions about this program, please call our Member Service Department toll-free at 1-800-538-8833. AGREEMENT I request and authorize Blue Cross and Blue Shield (BCBS) and/or its designee to obtain payment of.

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