Blue365 Authorization

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

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

This authorization does not permit Horizon Blue Cross Blue Shield of New Jersey to disclose any other information.

I understand that BCBSA needs to know I am enrolled in a Horizon Blue Cross Blue Shield of New Jersey 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 Horizon Blue Cross Blue Shield of New Jersey product and my IP address will be disclosed to BCBSA. Although Horizon Blue Cross Blue Shield of New Jersey 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 Horizon Blue Cross Blue Shield of New Jersey 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. Horizon Blue Cross Blue Shield of New Jersey 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 Horizon Blue Cross Blue Shield of New Jersey product that Horizon Blue Cross Blue Shield of New Jersey 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.

Last Updated 08/17/2012

I Agree

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