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Get CA Blue Shield A46163 2018-2024

S associates (collectively “Blue Shield”) to use or to disclose your health information to another person or organization. 1. Person whose information is to be disclosed (the “Member”). Member name and address: Subscriber ID number: Date of birth: 2. Who is authorized to receive the Member’s information (the “Recipient”)? Recipient’s name and address: Recipient’s relationship to the Member: 3. What information may be disclosed to the Recipient? (Check one) Blue Shield of Cal.

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