Blue 365 - Blue Cross Blue Shield of Massachusetts

Authorization to see more of Blue365

By clicking the "I AGREE" button, below, I authorize Blue Cross Blue Shield of Massachusetts to disclose to each Blue365 vendor on whose Web site link I click:

• The fact that I am enrolled in a Blue Cross Blue Shield of Massachusetts product.

This authorization does not permit Blue Cross Blue Shield of Massachusetts to disclose any other information.

I understand that Blue365 vendors need to know I am enrolled in a Blue Cross Blue Shield of Massachusetts 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 Blue Cross Blue Shield of Massachusetts product will be disclosed to that vendor. Although Blue Cross Blue Shield of Massachusetts 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 Blue Cross Blue Shield of Massachusetts 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. Blue Cross Blue Shield of Massachusetts 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 Blue Cross Blue Shield of Massachusetts product that Blue Cross Blue Shield of Massachusetts made before the revocation. Blue Cross Blue Shield of Massachusetts 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. By agreeing to go forward, I certify that I am enrolled in a Blue Cross Blue Shield of Massachusetts product.

I AGREE

I WOULD LIKE TO PRINT A COPY OF THIS AUTHORIZATION