Fillable Form Msi 378 - Bcbs Application For Benefits Employee Statement (Page 2 of 2) in pdf

Form Msi 378 - Bcbs Application For Benefits Employee Statement Page 2

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APPLICATION FOR BENEFITS

EMPLOYEE STATEMENT

PO Box 4030 Saskatoon SK S7K 3T2

306.244.1192 Toll-free in Saskatchewan 1.800.667.6853

Page 2 of 2

Fax 306.652.5751

AUTHORIZATION

I, the undersigned, declare that my answers are complete and accurate, and form part

of an application for benefits with Saskatchewan Blue Cross and/or Blue Cross Life

Insurance Company of Canada

. I understand that the personal information provided

herein as well as any other personal information currently held or collected in the future

by Saskatchewan Blue Cross and/or Blue Cross Life Insurance Company of Canada

may be collected, used, or disclosed to administer the terms of my policy or of the

group policy of which I am an eligible member, to develop and recommend suitable

products and services to me and to manage the Company’s business.

Depending on the type of coverage I carry, limited personal information may be

collected from and/or released to a third party. These include other Blue Cross

organizations, licensed physicians and/or any other healthcare professionals or

institutions, health and life insurers, the Medical Information Bureau, government and

regulatory authorities, any Saskatchewan Health Agency including the Saskatchewan

Prescription Drug Plan, the policy holder or certificate holder of any policy under which I

am a participant, and other third parties when required to administer the benefits

outlined in my policy or the group policy of which I am an eligible member.

I understand that my personal information will be kept confidential and secure. I

understand that I may revoke my consent at any time; however, if consent is withheld

or revoked, coverage may be denied or rescinded. I understand why my personal

information is needed and am aware of the risks and benefits of consenting or refusing

to consent to its disclosure. For additional information regarding the privacy policies of

Blue Cross and/or the collection, use or disclosure of my personal information, I can

visit or call 1-800-USEBLUE

Dated this ____________ day of ______________________________ 20_________

Signed ______________________________________________________________

Employee Signature

Witness ______________________________________________________________

®Saskatchewan Blue Cross, Blue Cross, Blue Cross Life Insurance Company of Canada and 1-800-USEBLUE are registered trade-marks of the Canadian Association of Blue Cross Plans, used

under license by Medical Services Incorporated, an independent licensee.

MSI 321 09/13

Attachment for MSI 378