Electronic Funds Transfer (Eft) Authorization Form - United Health Care

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Electronic Funds Transfer (EFT)
Authorization Form
Save time and money with Automatic Deduction from your checking or savings account.
You can have your monthly premium payments automatically deducted from your checking or savings account
using our Electronic Funds Transfer (EFT) process.
EFT is safe and convenient, plus it saves you money on postage. Your monthly Medicare Part D premium
payment will be automatically deducted on or around the fifth day of every month and forwarded to the plan by
your bank or financial institution.
EFT is one of the easiest ways to pay your Part D premium.
You don’t have to write out a check and mail it each month.
You won’t have to remember to mail your premium if you travel or become ill.
Your check will never be delayed or lost in the mail.
Signing Up For EFT Is Easy!
It takes just a few minutes to set up your monthly premium payment for automatic deduction from your
checking or savings account. All you have to do is:
Complete the Electronic Funds Transfer (EFT) Authorization Form below.
Write “VOID” on a blank check from the account you would like the EFT payments withdrawn from.
Do NOT send a deposit slip or cancelled check.
Return the completed Electronic Funds Transfer (EFT) Authorization Form and voided blank check to
UnitedHealthcare MedicareRx for Groups, 29350 Hot Springs AR 71903-9350. You will be notified by the
plan of the date your EFT begins.
You should continue to pay your monthly premium using your current payment method until that time.
Detach & mail with blank voided check
Electronic Funds Transfer EFT Authorization Form
I authorize UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New York
residents), insurer of the UnitedHealthcare MedicareRx for Groups (PDP) plan, to initiate monthly withdrawals, in
the amount of my current monthly premium, from the account named on this form and authorize the named banking
facility (BANK) to charge such withdrawals to my account.
Account Holder Name: ____________________________________________________________________________
Bank Name:_____________________________________________________________________________________
Bank Address:___________________________________________________________________________________
Bank Routing No.:_______________________ Savings/Checking Account #: _________________________________
The reverse side of this form must also be completed


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