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II. The Group further authorizes and directs BCBSI to disclose to HCFA all <br /> infonnation required under the Settlement Agreement to assist HCFA in <br /> identifying duplicate primary payments to Providers, the data elements required <br /> being attached to this Authorization as Attachment II. The Grou further a rees <br /> P � <br /> and authori <br /> zes BCBSI to disclose to HCFA 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: <br /> NAME OF GROUP <br /> MBER . <br /> SIGNAT <br /> TITLE: <br /> AUTHORIZED REPRESENTATIVE <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 /> NAME 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 />