Fillable Automatic Premium Payment Program Authorization Agreement o C (Blue Cross and Blue Shield of Texas)

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Automatic Premium Payment Program Authorization Agreement o C (Blue Cross and Blue Shield of Texas)

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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 MedicareRx (PDP)
c/o Member Services
P.O. Box 3897
Scranton, PA 18505
Your payments will be deducted on approximately the 4th of each month.
AGREEMENT
I, as account holder, hereby authorize 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 MedicareRx
SM
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
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 HISC by telephone prior to a scheduled withdrawal
date.
I am authorizing my insurance premium due for this Blue Cross MedicareRx 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.
Prescription drug plans provided by HCSC Insurance Services Company (HISC), an Independent
Licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor.
Enrollment in HISC's plans depends on contract renewal.
91433.0820
Y0096_PDPACH21_C
______________________________________________________
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)
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Automatic Premium Payment Program Authorization Agreement o C (Blue Cross and Blue Shield of Texas)

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Completed 10 February 2021

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