Automatic Premium Payment Program
Authorization Agreement
Take these three simple steps to hassle-free monthly premium payments:
o C
omplete 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 Dual Care
c/o Member Services,
P.O. Box 4555
Scranton, PA 18505.
Your payments will be deducted on approximately the 4th of each month.
I, as account holder, hereby authorize Health Care Service Corporation (HCSC) and/or HCSC
Insurance Services Company (HISC) 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 Dual Care (HMO SNP) 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 Dual Care
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
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
I have read and accept the above agreement.
Member Signature: _________________________________________________________________
Account Holder Signature(s): _________________________________________________________
(if different from Member)
HMO Special Needs Plan provided by Health Care Service Corporation, a Mutual Legal Reserve
Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. HCSC is
a Medicare Advantage organization with a Medicare contract and a contract with the New Mexico
Medicaid program. Enrollment in HCSC's plan depends on contract renewal.
- 478852.0820