Small Group Initial Payment Form
(1 - 100 employees)
Please complete this form to authorize an electronic debit payment for your first month’s dues/premium. For new
group submissions, submit with the Master Group Application. Note: This is a one-time payment option. To set up
recurring auto-payments, please visit Employer Connection after you receive your first billing statement.
Automatic debit form authorization and signature(s)
I authorize Blue Shield to initiate a one-time debit to the bank account shown below. This electronic debit should be
completed within three days before or after my group’s plan effective date for the payment of the first month’s dues/
premium for members covered by Blue Shield.
I also authorize my financial institution to reduce the balance of my group’s account by the amount shown (and/
or corrections to previous debits). If this item is returned unpaid, I authorize Blue Shield to mail a bill to the address on
record and the group will be responsible for making the payment by check or money order and for paying any return
item service charges in order for coverage to become effective. I understand that Blue Shield of California will appear
on bank statements as California Physicians’ Service.
By signing, I agree to the terms and conditions of this authorization form and acknowledge that I have received a copy
of this form.
Group name Group representative signature
Group representative name
City State ZIP code
Name of financial institution
Bank routing number Group checking account number
Dues/premium amount to be debited: $
Attached copy of voided check
The voided check is necessary for processing, in order to debit your account accurately.
Please note we are unable to accept the following checks or account types to process a debit payment: money orders,
credit cards, third-party checks, cashier’s checks, traveler’s checks, or government checks.
Please attach voided check here
For Blue Shield of California use only
Please retain a copy of this form for your records
Blue Shield of California is an independent member of the Blue Shield Association A44591-FF (6/18)
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