Anthem Blue Cross : HIPAA - Individual Member Authorization Form

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Anthem Blue Cross : HIPAA - Individual Member Authorization Form

PW_B156165

HIPAA – Individual Member Authorization Form

HIPAA – Individual Member Authorization Form (Spanish)

® Anthem is a registered trademark. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association © 2011 Anthem Blue Cross.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.