By clicking the “I AGREE” button, below, I authorize Blue Cross Blue Shield of Geography to disclose to Blue Cross and Blue Shield Association (“BCBSA”):

• The fact that I am enrolled in a Blue Cross Blue Shield of Geography product and my IP address.

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

I understand that BCBSA needs to know I am enrolled in a Blue Cross Blue Shield of Geography product to make discounts available to me.

Once I click on a link to visit BCBSA’s Blue365 web site, the fact that I am enrolled in a Blue Cross Blue Shield of Geography product and my IP address will be disclosed to BCBSA. Although Blue Cross Blue Shield of Geography will not give BCBSA my name or any other information about me, I understand that BCBSA’s Blue365 web site is not 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 Geography product and my IP address (subject to its privacy policies and any applicable state laws). I acknowledge that the Blue 365 web site includes products and services that are not health related.

This authorization is voluntary. Blue Cross Blue Shield of Geography 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 close the browser window after using the Blue 365 web site. 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 Geography product that Blue Cross Blue Shield of Geography made before the revocation. BCBSA may receive payment from vendors under the Blue 365 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.