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Members

 Blue365

Authorization to see more of Blue365

By clicking the “I AGREE” button below, I authorize Capital BlueCross to disclose to each Blue365 vendor on whose Web site link I click:

  • The fact that I am enrolled in a Capital BlueCross product.

This authorization does not permit Capital BlueCross to disclose any other information.

I understand that Blue365 vendors need to know I am enrolled in a Capital BlueCross product to give me discounts.

Once I click on a link to visit a Blue365 vendor’s Web site, the fact that I am enrolled in a Capital BlueCross product will be disclosed to that vendor. Although Capital BlueCross will not give the vendor my name or any other information about me, I understand that the vendor may not be subject to federal health information privacy laws and, therefore, could re-disclose the fact that I am enrolled in a Capital BlueCross product (subject to vendor's own privacy policies and any applicable state laws).

I acknowledge that the Blue365 Web site includes products and services that are not health related.

This authorization is voluntary. Capital BlueCross will not condition my enrollment in a health plan or eligibility or payment for benefits on receiving this authorization. I revoke this authorization and it expires immediately when I leave the Blue365 Web site by closing the browser window. When I revoke this authorization, the revocation will not affect any disclosure of the fact I am enrolled in a Capital BlueCross product that Capital BlueCross made before the revocation. Capital BlueCross may receive payment from vendors under the Blue365 program.

I have had full opportunity to read and consider the contents of this authorization. I understand that, by clicking on the “I AGREE” button below, I am confirming my authorization for the use and disclosure of information about me, as described in this form.

04/20/2014


I would like to Print A Copy of this authorization.

*The Blue365® program is brought to you by the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Association is an association of independent, locally operated Blue Cross and/or Blue Shield Companies. Blue365 offers access to savings on health and wellness products and services and other interesting items that Members may purchase from independent vendors, which are different from covered benefits under your policies with Capital BlueCross and its family of companies.