Fill out the form completely. Have each listed employee sign the form.The signature of the individuals specified above is considered as binding for as that of the responsible official. The sole purpose of this form is to authorize the above named representative to complete the transaction indicated. Acknowledgement: I authorize the following agents to purchase permits on my behalf, including under my license and use of my escrow account. WHEN COMPLETED AND SIGNED PLEASE MAIL TO: Blue Cross and Blue Shield of Texas. The Owner of Record may use this form to authorize a Third Party to process and pick up related items for motor vehicle transactions noted below. With this Letter of Authorization I give permission to the authorized individual in Section B to purchase the transaction type(s) I have circled above. This form should be used when authorizing Blue Cross and Blue Shield of Texas to disclose an individual's Protected Health. YES. NO. If "YES," also complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227). 23.