Fillable EFT-Form Electronic Funds Transfer Form

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EFT-Form Electronic Funds Transfer Form

On average this form takes 5 minutes to complete

The EFT-Form Electronic Funds Transfer Form form is 2 pages long and contains:

  • 1 signature
  • 2 check-boxes
  • 14 other fields

Country of origin: US
File type: PDF

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| HF FM 069MC EN REV 11/19
1. Applicant information
First Name:
Last name:
Family Member Number:
Monthly premium amount:
2. Banking Information
Bank Account Holder’s First Name:
Bank Account Holder’s Last Name:
Name of Bank:
Address of Bank Branch:
City:
State, Zip Code:
3. Account type:
Checking Bank Transit Routing number:
Savings Account number:
See Sample for Routing
& Account Numbers
• Routing Number: Located at the bottom left hand corner of the check, the routing number is the
first nine digits of the sequence.
• Account Number: Following the routing number the next 15 digits of the sequence is the account
number.
• Check Number: The last four digits of the sequence as well as the top right corner of the check is
the check number. Make sure not to include this into the account number.
Electronic Funds Transfer Form
| HF FM 069MC EN REV 11/19
4. Signature
I give permission to Medi-Cal For Families Program to begin withdrawing funds each month out
of the account described above, in the amount of the monthly premium.
Signature of Bank Account Holder Date
Printed Name of Bank Account Holder
NOTE:
• This permission to withdraw funds will remain in effect until Medi-Cal for Families
receives written notice from the applicant to discontinue the monthly electronic funds
transfer (EFT).
• In order to allow enough time to process your EFT form, you will need to pay your
premiums in another way until the EFT starts. Your options are:
• In person using Convenience Pay with Western Union.
• Credit/Debit Card/Bank Account Over the phone at 1-888-970-0626
• Online at www.dhcs.ca.gov/services/Pages/Medi-CalPremiumPayments.aspx
• Send check or money order to the Medi-Cal For Families address below
• The EFT will start approximately 6 to 8 weeks after you sign up. If the applicant
becomes no longer eligible for Medi-Cal For Families, the EFT will end.
• Please Enclose a blank, “VOID” check or savings deposit slip with your enclosed form.
(To “VOID” a check, write the word “VOID” across the front of the check)
• Please complete this entire form and mail to:
Medi-Cal For Families
Premium Payment Section
PO Box 7187
Pasadena, CA, 91109-7187
Questions? Call 1-800-880-5305, Monday to Friday, 8 a.m. to 7 p.m., or, on Saturday,
8 a.m. to 12 p.m. The call is free.
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EFT-Form Electronic Funds Transfer Form

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Completed 3 July 2020

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