Recurring Direct Debit Authorization Form - Cigna Medicare Rx (Pdp) (Page 2 of 2) in pdf

R ecurring Credit Card Authorization Form

ONLY complete if you want your premium automatically charged to your credit card.

DO NOT complete both sides of this form.

Member Name: _____________________________________________

Member ID Number: ___________________________________________

________________________________________________________________________________________

Credit Card Type:

VISA

Master Card

Credit Card Number:

Credit Card Expiration Date:

Month Year

Cardholder Name (as it appears on your Credit Card): ____________________________________

Cardholder Billing Address:

______________________________________________

City: ___________________________ State: ______ Zip: _____________

___________________________________________________________________________________________

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

sponsor) to charge my credit card listed above the amount of my monthly CIGNA Medicare Rx

premium as stated in my Evidence of Coverage. This charge will occur once per month and will

continue as long as I am enrolled in the CIGNA Medicare Rx 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 charged to my credit card.

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.

Recurring Direct Debit Authorization Form - Cigna Medicare Rx (Pdp) Page 2