Fillable Automatic Premium Payment Program Authorization Agreement Tak o (BlueCross BlueShield of New Mexico)

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Automatic Premium Payment Program Authorization Agreement Tak o (BlueCross BlueShield of New Mexico)

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Automatic Premium Payment Program
Authorization Agreement
Tak
e these three simple steps to hassle-free monthly premium payments:
o Complete and sign this authorization agreement.
o Verify with your financial institution that they can accept automated electronic
withdrawals.
o Return this authorization to:
Blue Cross Medicare Advantage
c/o Member Services
P.O. Box 4555
Scranton, PA 18505
Your payments will be deducted on approximately the 4th of each month.
AGREEMENT
I, as account holder, hereby authorize Health Care Service Corporation (HCSC) and/or HCSC
Insurance Services Company (HI
SC) to initiate withdrawals on a monthly basis from my account at
the
financial
institution named in this authorization for payment of monthly Blue Cross Medicare
Advantage(HMO) , Blue Cross Medicare Advantage (HMO-POS) , Blue Cross Medicare
Advantage (HMO SNP) , or Blue Cross Medicare Advantage (PPO) insurance premium due for
the named policyholder; and I authorize the financial institution to charge such withdrawals to my
account.
A draft shall be drawn each month on or about the premium due date of the policy/contract. As the
account holder, by signing below, I also certify, in the event that this draft is being drawn from a
company checking account, that I am authorized to approve this transaction, that the company is not
paying any portion of the premium for this subscriber, either directly or through reimbursement, and
that the employer/company is not deducting any part of the premiums from gross income under section
106 or section 162 of the Internal Revenue Code. I understand that both the financial institution and
HCSC and/or HISC reserve the right to terminate this payment program and/or my participation
therein. I also understand that I may discontinue this payment program (except on individual temporary
contracts) at any time with at least 10 days advance notice to HCSC and/or HISC by telephone prior to
a scheduled withdrawal date.
I am authorizing my insurance premium due for this Blue Cross Medicare Advantage coverage be paid
as described in this agreement and agree that if any withdrawal is dishonored, the premium payment
for such withdrawal will be considered in default. I also authorize the disclosure of my policy
identification/group numbers and any other necessary personal information on the financial
institution’s statements to identify to the account holder named for whom withdrawals are being made.
Please turn over
Y0096_MAPDACH21_C
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______________________________________________________
PLEASE COMPLETE THE FOLLOWING • Print or type information
Yes, I elect to have my insurance premium paid monthly through the Automatic Premium
Payment Program.
Member Name: __________________________________________________________________
Group Number: ____________________________ Member ID: ___________________________
Address: _________________________________________________________________________
City: ___________________ State _______________ ZIP: ___________ Phone #:_____________
Account Holder Name(s): ____________________________________ Phone #:________________
Account Holder Address: ____________________________________________________________
Full Name of Bank or Financial Institution:
Bank Account Number: __________________________________ • Checking OR • Savings
Routing Number: _______________________________________
I have read and accept the above agreement.
Member Signature: _________________________________________________________________
Account Holder Signature(s) _________________________________________________________
(if different from Member)
HMO plan in New Mexico, HMO and HMO-POS plans in Illinois, and PPO plans in Illinois,
Montana, and New Mexico are provided by Health Care Service Corporation, a Mutual Legal Reserve
Company (HCSC). HMO Special Needs Plan in New Mexico provided by HCSC. HMO, PPO, and
Dual Care HMO Special Needs plans in Texas provided by HCSC Insurance Services Company
(HISC). HMO plans in Texas provided by GHS
Insurance Company (GHS). All HMO and PPO
employer/union group plans provided by HCSC. Oklahoma PPO plans for employer and union
groups only. HMO plan in Oklahoma provided by GHS Health Maintenance Organization, Inc. d/b/
a BlueLincs HMO (BlueLincs). HCSC, HISC, GHS, and BlueLincs are Independent Licensees of the
Blue Cross and Blue Shield Association. GHS and BlueLincs are Medicare Advantage organizations
with a Medicare contract. HCSC is a Medicare Advantage organization with a Medicare contract and
a contract with the New Mexico Medicaid program. HISC is a Medicare Advantage organization with
a Medicare contract and a contract with the Texas Medicaid program. Enrollment in these plans
depends on contract renewal.
91432.0321
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Automatic Premium Payment Program Authorization Agreement Tak o (BlueCross BlueShield of New Mexico)

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Completed 27 March 2021

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