As described in its Notice of Privacy Practices, Highmark Inc. (Highmark) has very strict policies on how it protects all of the information it collects when providing you with and managing your health insurance. Certain kinds of information such as your name, address, and medical history are considered to be Protected Health Information (PHI).

Highmark and affiliated entities, as well as other entities Highmark has contracted with, offer a variety of health-related and certain additional insurance-related products and services that may be of interest to you. Highmark may, at times, want to provide you with relevant products and services offerings and it needs your permission to use any of your PHI to do so. This authorization permits Highmark and its affiliated entities to use this information to contact you about these products and services.

I hereby authorize Highmark Inc. (Highmark) and its affiliates and subsidiaries to use the information set forth below to contact me about the products and services identified below that may interest me. This authorization also permits these entities to contact me about these products and services.

I authorize Highmark Inc. (Highmark) and its affiliates and subsidiaries to use the protected health information (PHI) it has about me (such as my name, address and other health-related information) to identify products and services that may be of interest to me and then to contact me about these products and services. I recognize that I am not obligated to purchase or use any of these products or services. These products and services include health-related or insurance-related products and services that Highmark believes may be of interest to me, whether offered by Highmark or other entities. I recognize and acknowledge that in some of these circumstances Highmark may receive payment in connection with these products and services.

I understand that this authorization is voluntary. Highmark does not condition my enrollment in a health plan or my eligibility for benefits or payment of claims in a health plan on my signing this authorization.

I understand that my PHI may be shared with other parties not subject to health information privacy laws. I also understand that, to the extent any information is shared with other entities, that it will be shared only for the purpose of sending me communications about these products and services, and that any entity that is provided this information must abide by specific safeguards and contractual restrictions that protect my privacy. If I choose to purchase or use any of these products or services, I also may be asked to provide information to these other entities in order to obtain these products or services.

I can accept the terms and conditions of this authorization by selecting the box indicating "I have read and ACCEPT the Other Products and Services Authorization." I understand that this will mean that I have read this authorization and am authorizing Highmark and its affiliates and subsidiaries to use my PHI as described above.

I may revoke this authorization at any time by deselecting the box indicating "I have read and ACCEPT the Other Products and Services Authorization." I understand that if I revoke this authorization it will not affect any action that Highmark and its affiliates and subsidiaries took in reliance on this authorization. I also understand that my PHI can continue to be used for purposes permitted by the privacy rules, regardless of this revocation. Unless otherwise revoked, this authorization will expire when I cease to be a beneficiary of a product under which I am covered by, or serviced by, Highmark and/or its affiliates and subsidiaries.

You are entitled to a copy of this authorization after you sign it.