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Get CA Blue Shield A46163 2017

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: c A  ny or all information Blue Shield maintains. This may include information rel.

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