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Get TX Blue Cross Blue Shield SAF-TX 2019-2024

To disclose your protected health information (PHI) to a specific person or entity. You may follow the instructions below or call the number listed on your Member ID card if you need help completing the form. You must complete the entire form. Please note: One authorization form can be used for multiple services or providers or you can complete the form claim by claim, procedure by procedure, or for services provided during certain time periods. The use of the authorization form is volu.

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