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California Authorization Use Form 2018-2023
Information (the “Recipient”)?
Recipient’s name and address:
Recipient’s relationship to the Member:
3. What information may be disclosed to the Recipient? (Check one)
Blue Shield of California is an independent member of the Blue Shield Association A46163 (2/18)
c A
ny or all information Blue Shield maintains. This may include information
relating to the Member’s medical care, diagnosis, providers, insurance or
benefit claims/payments, and/or financial/billing information. This does
not...
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