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_ , <br /> II. T'he Group furthe:authorizes and directs BCBSI to disclose to HCFA all <br /> info:mation required und�r the Settlement A`r�ement to assist HCFA in <br /> ider.tifying duplicate primary payments to Providers, the data elements required <br /> being attached to this Authorization as Attachment II. The Group further aarees <br /> and authorizes BCBSI to disclose to HCFR any supporting documentation <br /> requested by HCFA in connection with identified duplicate primary payments <br /> such as canceled checks and explanations of benefits. <br /> Date: 2�23/96 City of Decatur, Illinois <br /> NA1�1E OF GROUP <br /> 992844 and P06856 <br /> GRO ER <br /> BY: , <br /> SIGNATURE <br /> TITLE: �YOR <br /> AUTHORIZE ENTATIVE <br /> OR <br /> The Group does not authorize disclosure of data to HCFA or cooperation in the Data <br /> Match or duplicate payment process, all as described above. ' <br /> Date: <br /> NAi�fE OF GROUP <br /> GROUP NUMBER <br /> BY: <br /> SIGNATURE <br /> TITLE: <br /> AUTHORIZED REPRESENTATIVE <br /> This form must be returned to Blue Cross and Blue Shield of Illinois no later than <br /> February 16, 1996. <br />