Enrollment instructions
1. Complete the form below.
2. List all customer numbers and bill groups that you wish to have paid by automatic withdrawal.
3. Fax this form to the fax number on the bottom of the Authorization form.
Statement of understanding
By executing this document in the space provided below, I hereby confirm that I am authorized to act on behalf of the employer/
customer (“Group”) described below and agree on behalf of Group to the following terms and conditions:
Group authorizes UnitedHealthcare to debit the group checking (account number provided below) for all monthly charges for
coverage.
Group understands that it may take up to one month to set up Scheduled Direct Debit, and, consequently, all overdue premiums should
be promptly paid in order to avoid receiving a delinquency letter and possible termination of your account during this initial setup period.
Group understands and agrees that it will have sufficient funds in its account to cover the full premium invoice on the draft due date.
e draft due date will be the 10th of the month for which the invoice applies. If necessary funds are not in your account on the
draft due date, group coverage may be subject to termination proceedings consistent with the terms stated in your UnitedHealthcare
contract.
Group agrees to promptly notify UnitedHealthcare of any change to the information provided.
Authorization
Authorization is given to UnitedHealthcare to initiate debits (payments) to the financial institution indicated below. is financial
institution is authorized to debit the account. is authority is to remain in full force and effect until a 30-day revocation notice
is written to UnitedHealthcare; or it is cancelled by UnitedHealthcare under the conditions stated above; or upon termination of
coverage with UnitedHealthcare.
Determining your routing number
To determine your routing number, refer to
your company check. e routing number is
ALWAYS 9 digits long and it is enclosed by
colons. e location of the routing number
and account number on your company check
varies depending on the bank; for example:
I have read and agree to the terms and conditions outlined above.
Authorized signature and title of signatory Date
Employer name/Customer name/Policy name Employer e-mail address
Group number UnitedHealthcare customer number and bill group(s)
Name of your financial institution Telephone number of financial institution
Routing/Transit Number (9 Digits) Account Number (include all zeroes and omit spaces/special characters)
Mail to: UnitedHealthcare
Attn: Remittance Easy Pay Set Up
5701 Katella Ave. CA120-0351
Cypress, CA 90630
OR Fax to: 1-866-392-7071
Attn: Remittance Easy Pay Set Up
Health plan coverage provided by or through UnitedHealthcare Insurance Company and UnitedHealthcare of California.
Administrative services provided by PacifiCare Health Plan Administrators, Inc., Prescription Solutions or OptumHealth Care
Solutions, Inc. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC) or United Behavioral
Health (UBH).
4/11
© 2011 United HealthCare Services, Inc.
PCA325730-002
YOUR NAME
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|:123456789|: 987654321 0301
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YOUR BANK
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Routing# Account# Check#
Bank 1 Bank 2
YOUR NAME
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|:123456789|: 0301 987654321
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YOUR BANK
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Bank 3
YOUR NAME
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0301 |:123456789|: 987654321
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YOUR BANK
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Check# Routing# Account#
Scheduled Direct Debit Authorization Form
