Standard Authorization Form (Illinois) (Page 2 of 2) in pdf

Standard Authorization Form (Illinois) Page 2

IV. Expiration and Revocation:

Expiration: This authorization will expire on (must choose one):

One year from the date it is signed

Other (insert date or event):

Right to Revoke: I understand that I may revoke this authorization at any time by giving written notice to the address listed at the bottom of

this form. I understand that revocation of this authorization will not affect any action the above named entity took in reliance on this

authorization before the above named entity received my written notice of revocation.

V. Signature

(this document must be signed by the individual, parent of minor child or the individual's personal representative)

I understand that this authorization is voluntary and that the health plan cannot condition my eligibility for benefits, treatment,

enrollment or payment of claims on the signing of this authorization. I understand that if I am signing on

behalf of a minor child, this

authorization will expire upon the child reaching the age of 18, unless there is proof of legal guardianship.

____________________________________________________________

_______________________

Signature

Date: month/day/year

If you are signing as a Power of Attorney, Legal Guardian, Executor or Administrator complete the following and attach a copy of

the Legal documents. You do NOT

have to attach copies of these documents if they are already on

file with Blue Cross and Blue

Shield of Illinois:

Personal Representative’s Name

Relationship to Individual

Personal Representative’s Address

City

State

ZIP

Personal Representative’s Area Code & Telephone Number

BEFORE RETURNING YOU SHOULD KEEP A COPY FOR YOUR RECORDS

BY EITHER:

(1) MAKING A PHOTOCOPY OF THIS SIGNED AUTHORIZATION; OR

(2) COMPLETING AND SIGNING THE DUPLICATE AUTHORIZATION FORM YOU RECEIVED OR

PRINTED

Mail your completed signed authorization to:

Blue Cross and Blue Shield of Illinois

P.O. Box 805107

Chicago, IL 60680-4112

If you need assistance completing the form, please contact the Customer Service number listed on the back

of your Member Identification Card.

Rev. 09/28/07 – HCSC Regulatory Office

Page 2 of 2

Standard Authorization Form

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company

an Independent Licensee of the Blue Cross and Blue Shield Association

Standard Authorization Form (Illinois) Page 2

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