Blue 365 - Wellmark

Authorization to see more of Blue365

By clicking the "I AGREE" button, below, I authorize Wellmark to disclose to each Blue365 vendor on whose Web site link I click:

• The fact that I am enrolled in a Wellmark product.

This authorization does not permit Wellmark to disclose any other information.

I understand that Blue365 vendors need to know I am enrolled in a Wellmark 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 Wellmark product will be disclosed to that vendor. Although Wellmark 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 Wellmark 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. Wellmark 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 Wellmark product that Wellmark made before the revocation. Wellmark 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 Wellmark product.

I AGREE

I WOULD LIKE TO PRINT A COPY OF THIS AUTHORIZATION