Fillable Form 3291-Ek Automatic Payment Form printable pdf download

AUTOMATIC

PAYMENT FORM

AUTOMATIC CHECKING ACCOUNT WITHDRAWAL AUTHORIZATION

Please complete the section below and ATTACH A VOIDED CHECK if you would like to have your US Family

Health Plan Enrollment Fee deducted from your checking account.

I, __________________________________________________, authorize Johns Hopkins Medical Services Corporation to

withdraw my monthly enrollment fee from my checking account at the financial institution listed below.

I understand that I am responsible for making certain that adequate funds are available in my account for

withdrawal and will be liable for any charges incurred for insufficient funds. This authorization remains

in effect unless I cancel in writing or it is voided by Johns Hopkins Medical Services Corporation.

Sponsor’s Name ______________________________________________________________ Sponsor’s DOB___________________________

My Name _____________________________________________________________________ My DOB_________________________________

My Email Address _________________________________________________________________________

Financial Institution ______________________________________________________________________________________________________

Address ____________________________________________________________________________________________________________________

Routing Number __________________________________________________ Account Number___________________________________

To the best of my knowledge this information is correct.

____________________________________________________________

______________________________________________

Signature

Date

CREDIT CARD AUTHORIZATION

Please complete the section below if you would like to have your US Family Health Plan Enrollment Fee charged

to your credit card. We accept MasterCard, Visa and Discover.

I, __________________________________________________, authorize Johns Hopkins Medical Services Corporation to

charge my (circle one) Monthly or Quarterly enrollment fee to my credit card listed below. I understand that

I am responsible for making certain that adequate credit is available and will be liable for any charges incurred for

insufficient credit. This authorization remains in effect unless I cancel in writing or it is voided by Johns Hopkins

Medical Services Corporation.

Sponsor’s Name _______________________________________________________________ Sponsor’s DOB_________________________

My Name ______________________________________________________________________ My DOB_________________________________

My Email Address _________________________________________________________________________

MasterCard

Visa

Discover Card

Card # ___________________________________________________ _____________ Expiration Date ____________________________

To the best of my knowledge this information is correct.

____________________________________________________________

______________________________________________

Signature

Date

MAKE A COPY OF THIS FORM FOR YOUR RECORDS. If you change or close your account, please contact us. In the event that your payment

does not clear, you will be notified and asked to reconcile as soon as possible so that your health care coverage will not be disrupted.

3291-EK (10/12)

Form 3291-Ek Automatic Payment Form