Authorization agreement
for autopay (EFT)
A. Complete and sign below as account holder for automatic bank deduction of premium.
B. Attach a copy of your voided check from the account to be drafted.
Applicant Account holder
Bank name
Account no. Routing no.
� New setup � Change financial institution
� Change account number � Change account type
I authorize Moda Health to charge my (individual or joint) checking account for monthly health premium for the above individual. I also authorize
my bank named here to honor these monthly charges. This authority will remain in effect until I give my bank a reasonable chance to act upon it.
I can stop payment by notifying my bank before my account is charged.
Authorizing payment does not guarantee coverage. The first monthly premium amount will not be debited from your account until your
application for individual health plan coverage has been approved by Moda Health Underwriting. You will be notified in writing of your application
status no later than 60 days from receipt. If your application is approved, the coverage effective date will be the first day of the month following
approval. If your application is not approved, you will be notified in writing, and your account will not be debited.
Signature
X
Signature date
0539 (10/20)
Ready to submit? Mail or fax this form with a copy of a voided check to Moda Health:
Mail: Moda Health, Attn: Billing and Eligibility, 601 S.W. Second Ave., Portland, OR 97204-3156
Fax: 503-219-3696 Attn: Billing & Eligibility Individual
Questions? Contact Moda Health Customer Service at 888-217-2365. (TTY users, dial 711.)
modahealth.com
9-digit routing no. Account no.
Section 1 Transaction type
Section 2 Initial payment information
Section 3 Recurring payment information
Section 4 Authorization
Draft monthly recurring payment from:
� Same bank � Different bank (indicated below)
Account holder Bank name
Bank routing no. Account no.
Health plans in Oregon and Alaska provided by Moda Health Plan, Inc. Dental plans in Oregon provided by
Oregon Dental Service. Dental plans in Alaska provided by Oregon Dental Service doing business as Delta
Dental of Alaska. Delta Dental is a trademark of Delta Dental Plans Association.
click to sign
signature
click to edit
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