Electronic Funds Transfer (Eft) Authorization Form - United Health Care Page 2
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1
2Please remember to notify us if:
•
You move to another state, since it may affect your monthly premium.
•
The bank you use changes its name or merges with another bank. Please call your bank for the new
account number.
•
You change banks.
If someone else handles the finances for your account, please call a UnitedHealthcare Customer Care
Professional at the phone number listed below for special instructions.
This diagram is for informational purposes only. Please do not send a
deposit slip or cancelled check. Blank checks must be voided to set up EFT.
Check Sample
101
John Doe
123 w. Main St.
DATE
Anytown, USA 12345
$
PAY TO
THE ORDER OF
DOLLARS
YOUR BANK
ANYTOWN, USA
FOR
101010011
05510051151
101
Bank Routing Number
Bank Account Number
Please refer to the above diagram to obtain your bank routing information. If you have questions
regarding EFT, please call a UnitedHealthcare Customer Care Professional at 1-888-556-6648, TTY users
should call 711, 8 a.m.– 8 p.m., 7 days a week.
Plans are insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a
Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor.
This authority remains in effect until UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company
of New York for New York residents) and the named banking facility receives notification from me of its termination
in such time and manner as to give UnitedHealthcare Insurance Company and the banking facility a reasonable
opportunity to act on it. I have the right to stop payment of a withdrawal by notification to the named banking facility
in such time as to give the banking facility a reasonable opportunity to act upon it, with the understanding that such
action may put my plan account past due.
Member Name:__________________________________________________________________________________
Member Address: _______________________________________________________________________________
City:_______________________________________________State: __________________Zip: _________________
Member Phone Number: (_____)________________________ Member ID Number: __________________________
Signature:___________________________________________________________Date: _______/_______/_______
EFPDP2379_XUHE004 R 8/11
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