By selecting the "I AGREE" button, below, I authorize Health Advantage to disclose to each Blue365 vendor on whose website link I select:
This authorization does not permit Health Advantage to disclose any other information.
I understand that Blue365 vendors need to know I am enrolled in an Health Advantage product to give me discounts.
Once I click on a link to visit a Blue365 vendor's website, the fact that I am enrolled in an Health Advantage will be disclosed to that vendor. Although Health Advantage 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 Health Advantage product (subject to vendor's own privacy policies and any applicable state laws).
I acknowledge that the Blue365 website includes products and services that are not health related.
This authorization is voluntary. Health Advantage 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 website 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 Health Advantage product that Health Advantage made before the revocation. Health Advantage 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 selecting "I AGREE", below, I am confirming my authorization for the use and disclosure of information about me, as described in this form.
I WOULD LIKE TO PRINT A COPY OF THIS AUTHORIZATION.
Health Advantage is an Independent Licensee of the Blue Cross and Blue
Shield Association and is licensed to offer health plans in all 75 counties in Arkansas.
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