RCUH Policies and Procedures
An Independent Licensee of the Blue Cross and Blue Shield Association
HMSA Subscriber Name:
HMSA Subscriber ID Number:
Account Holder Name(s):
Account Type: Checking (1) Savings (2)
I allow HMSA and my financial institution to transfer money from my account to pay my HMSA premiums. HMSA will notify me if the premium amount changes as a result of an annual rate change. I can continue automatic transfers from my account under this agreement or discontinue it with a written request to HMSA. The account is from a U.S. financial institution.
I understand that either HMSA or I can end automatic payments with 30 days’ written notice.
(As shown on financial institution records.)
For HMSA Use Only
HMSA Group Number:
IMPORTANT: For a checking account deduction, attach a VOIDED personal check below. For a savings account deduction, attach a statement to this form. Be sure the name of your financial institution and your account number appear on the check or statement. Please complete one authorization form per membership.