Bank name
Account type
Account number
Conrm account number
Routing number
Account numberRouting number (9 digits)
Enroll in auto-pay
Have your bill automatically paid each month with the bank
account you chose in the section above.
Enroll in paperless billing
Save paper and have your bill emailed to you and your team
each month.
I hereby authorize Cigna + Oscar, including its parent, affiliates and subsidiaries (Cigna Health and Life Insurance Company + Mulberry
Management Company) to initiate entries to the checking/savings account at the financial institution listed above, and, if necessary, initiate
adjustments for any transactions credited/debited in error. This authority will remain in effect until Cigna + Oscar notifies me that this service
has been discontinued, or I notify Cigna + Oscar in writing to cancel it in such time as to afford Cigna + Oscar and the financial institution a
reasonable opportunity to act on my request. I agree to notify Cigna + Oscar in writing of any changes in my account information at least 15
days prior to the next billing date. If payment dates fall on a weekend or holiday, I understand that the payments may be executed on the
next business day. I understand that ACH debits to the checking/savings account are electronic transactions and funds may be withdrawn from
the account as soon as the above noted periodic transaction dates. I certify that I am an authorized user of this credit card/bank
account and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the
terms indicated in this authorization form.
Billing contact (print full name)
Group number (if available)
Business name
Section A: Business billing information
Section B: ACH account information
Section C: Payment settings
Section D: General agreement
Signature of applicant Printed name Date (mm/dd/yyyy)
Sign here
ACH Authorization Form
Fill out the following
form to allow Cigna + Oscar to store and debit payments from your bank account. By submitting this form, you are
authorizing Cigna + Oscar to debit the first month’s full premium automatically upon approval. Subsequent payments will be deducted
automatically only if auto-pay is selected. ACH payments are easy and will help get your employees their member ID cards faster and easier!
Cigna + Oscar coverage is insured by Cigna Health and Life Insurance Company.
Benefits administered by Oscar Health Administrators. Pharmacy benefits are provided by Express Scripts, Inc.