Recurring Direct Debit Authorization Form - Cigna Medicare Rx (Pdp) printable pdf download

Recurring Direct Debit Authorization Form - Cigna Medicare Rx (Pdp)

Recurring Direct Debit Authorization Form

ONLY complete if you want your premium automatically deducted from your bank

account. DO NOT complete both sides of this form.

Member Name: ________________________________________________________

Member ID Number: ___________________________________________________

Type of Account:

C hecking

S avings

If you are using a checking account, you MUST tape ONLY a voided check here.

If you are using a savings account, you MUST tape ONLY a voided deposit ticket here.

DO NOT attach both. This will insure accuracy in processing your request.

Thank you.

I hereby authorize Connecticut General Life Insurance Company (my CIGNA Medicare

Rx (PDP) plan sponsor) to deduct from my bank account listed above the amount of my

monthly CIGNA Medicare Rx (PDP) premium as stated in my Evidence of Coverage.

This deduction will occur once per month and will continue as long as I am enrolled in the

CIGNA Medicare Rx (PDP) plan or until I select another payment method. If the monthly

premium amount changes, I will be notified in writing prior to any changes in the amount

deducted from my bank account.

Account Holder Signature: _______________________________________

Today’s Date: _______ / _______ / _______

MAIL THIS COMPLETED AND SIGNED FORM TO:

CIGNA Medicare Rx (PDP)

PO Box 269005

Weston, FL 33326-9927

Or Fax to 1-800-735-1469

Questions Call: 1-800-222-6700 TTY/TDD Users Call: 1-800-322-1451

8:00 am - 8:00 pm, local time, 7 days a week.

"CIGNA Medicare Services," "CIGNA Medicare Rx" (PDP) and the "Tree of Life" logo are registered

service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its

operating subsidiaries. CIGNA Medicare Rx (PDP) plans are offered by operating subsidiary

Connecticut General Life Insurance Company, and not by CIGNA Corporation. > Connecticut

General Life Insurance Company is a Medicare approved Part D sponsor.

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Recurring Direct Debit Authorization Form - Cigna Medicare Rx (Pdp)