Be filled out in its entirety; 2. The signer need not sign in the notary's presence but must personally appear before the notary and state that the signature on the document is his or hers.Individual, parent of minor child, or the Individual's personal representative. Mail to State of Illinois, P.O. Box 19138, Springfield, IL 62794-9138 or b. Use this form to authorize Blue Cross Blue Shield of Illinois to disclose your protected health information (PHI) to a specific person or entity. The Voucher Signature Authorization Form is used to provide specimen signatures to the Comptroller for persons authorized to. Use this form to authorize Blue Cross Blue Shield of Illinois to disclose your protected health information (PHI) to a specific person or entity. How to fill out the Illinois Uniform Prior Authorization Form? Check statement that applies: ❏ 1. To fill out this form click in the space after First Name.

Authorization Letter With Signature In Illinois

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