Authorization Agreement For Automatic Withdrawal Form - Premera Blue Cross printable pdf download

PREMERA BLUE CROSS MEDICARE ADVANTAGE PLANS

Authorization Agreement for Automatic Withdrawal

(Electronic Funds Transfer—EFT)

I authorize Premera Blue Cross Medicare Advantage Plans to withdraw from my bank account

(indicated below) the rate for my monthly premium, and any outstanding premiums due at the

time of withdrawal. I understand that I will need to submit my first month’s premium separately, as

Electronic Fund Transfer may take more than one month to become active.

Member Name (please print): _______________________________________________________________

Address: _________________________________________________________________________________

City: ___________________________________________ State: ____________ Zip: __________________

Telephone #: (________) __________________________ Subscriber ID: ____________________________

Check this box if you are currently set up for automatic withdrawal and you wish to change bank account numbers.

From which account is the payment

Sample

1234

Find Your

to be withdrawn?

Pay to the order of

Routing and

Dollars

Checking

Account

Savings

1234567 89

12345 6789123

1234

Numbers:

Routing # Account #

Check #

Money Market

Bank Name: ____________________________________

Bank Routing #: _________________________________ Account #: _______________________________

This authorization is to remain in effect until I have notified Premera Blue Cross Medicare Advantage

of my request to terminate.

Signature: ______________________________________________________ Date: ____________________

Please remember that you are responsible for your first month’s premium, to be paid

separately, as Electronic Fund Transfer can take more than one month to become active.

In order for us to process your request:

Attach a voided or canceled check for the EFT account

Complete this form in its entirety, making sure all blanks are filled

Return the white copy to Premera Blue Cross and keep the yellow copy

Your premium will be withdrawn between the 15th and 20th of each month. To cancel your automatic

withdrawal or if you have any questions, please contact Premera Blue Cross Medicare Advantage

Plans Customer Service at 888-850-8526 (TTY: 711), 8 a.m. to 8 p.m., 7 days a week.

OFFICE USE ONLY

Received Date

Effective Date

Accounting Date

Premera Blue Cross Medicare Advantage Plans, P.O. Box 4196, Portland, OR 97208-4196

Premera Blue Cross is an HMO and HMO-POS with a Medicare contract. Enrollment in

Premera Blue Cross depends on contract renewal.

H7245_PBC0534_Accepted

028200 (10-2015)

Authorization Agreement For Automatic Withdrawal Form - Premera Blue Cross

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