You should fill out the cause number, style, court number, and county before going to court. Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure.This form should be used when authorizing Blue Cross and Blue Shield of Texas to disclose an individual's Protected Health. Mention your name and a short description of who you are. The sole purpose of this form is to authorize the above named representative to complete the transaction indicated. Fill out the form accurately: Ensure all fields are filled out correctly and completely. If you are authorizing someone to act on behalf of the company, there must be proper documentation to verify this. Fill out the petition and order.