Blue365 Disclosure/Agreement

By clicking the "I AGREE" button, below, I authorize BlueCross BlueShield of Western New York to disclose to BlueCross and BlueShield Association ("BCBSA"):

The fact that I am enrolled in a BlueCross BlueShield of Western New York product and my IP address.

This authorization does not permit BlueCross BlueShield of Western New York to disclose any other information.

I understand that BCBSA needs to know I am enrolled in a BlueCross BlueShield of Western New York 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 BlueCross BlueShield of Western New York product and my IP address will be disclosed to BCBSA. Although BlueCross BlueShield of Western New York 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 BlueCross BlueShield of Western New York product and my IP address (subject to its 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. BlueCross BlueShield of Western New York 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 Blue365 web site. When I revoke this authorization, the revocation will not affect any disclosure of the fact I am enrolled in a BlueCross BlueShield of Western New York product that BlueCross BlueShield of Western New York made before the revocation. BCBSA 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.

Sun Apr 20 09:30:45 EDT 2014

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