Medavie Blue Cross Change Form (Page 2 of 2) in pdf

Medavie Blue Cross Change Form Page 2

PRIVACY STATEMENT

I understand that the personal information provided herein, as well as any other

personal information currently held or collected in the future by Medavie 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 the group policy of

which I am an eligible member, to recommend suitable products and services to

me*, and to manage Blue Cross’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 third parties include other Blue Cross organizations, health

care professionals or institutions, life and health insurers, government and

regulatory authorities, and other third parties when required to administer and

manage the benefits outlined in the 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, in some

instances doing so may prevent Blue Cross from providing me with the requested

coverage or benefits. I understand why my personal information is needed and I

am aware of the risks and benefits of consenting or refusing to consent to its

disclosure.

A photocopy of this authorization shall be as valid as the original. This consent

complies with federal and provincial privacy laws. For additional information

regarding privacy policies at Medavie Blue Cross, visit

or call 1-800-667-4511.

*not applicable in Ontario or Quebec

Medavie Blue Cross Change Form Page 2