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Get Illinois Circuit Breaker 2016 Application

D that if I refuse to sign this authorization that BCBSNC and/or USAble Life may refuse to enroll me or determine that I am not eligible for benefits in BCBSNC and/or USAble Life. I understand that my protected health information is individually identifiable health information, including demographic information, collected from me or created or received by a health care provider, a health plan, or a health care clearinghouse and that relates to: (i) my past, present, or future physical or mental.

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