Electronic Funds Transfer (Eft) Authorization Form Page 2
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1
2Please remember to notify us if:
•
•
The bank you use changes its name or merges with another bank. Please call your bank for the new
account number.
•
You change banks.
This diagram is for informational purposes only. Please do not send a
deposit slip. Bank checks must be voided to set up EFT.
Check Sample
101
John Doe
123 W. Main St.
DATE
A
n
y
o t
w
, n
U
S
A
1
2
3
4
5
$
PAY TO
THE ORDER OF
DOLLARS
YOUR BANK
ANY TOWN, USA
Do not include
FOR
Check Number
101010011
05510051151
101
on form.
Bank Routing Number
Bank Account Number
Please refer to the above diagram to obtain your bank routing information. If you have questions
regarding EFT, please call UnitedHealthcare Customer Service at the number on the back of your
member ID card.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies,
a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D
sponsor. Enrollment in the plan depends on the plan’s contract renewal with Medicare.
me of its termination in such time and manner as to give UnitedHealthCare Insurance Company and the banking
opportunity
the
named banking facility in such time as to give the banking facility a reasonable opportunity to act upon it, with the
understanding that such action may put my plan account past due.
Member Name: _____________________________________
Member ID #: ______________________________
Member Address: _______________________________________________________________________________
City: ___________________________________________ State: _________________
Zip: _________________
Member Phone #: (________)__________________________
IR_PDP2378E_0005M
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