Get Surepay Online

Filling out the Surepay Online authorization form is a straightforward process that helps you manage your premium payments effortlessly. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and painlessly.

Follow the steps to complete the Surepay Online authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the personal information of the person to be billed, including their last name, first name, middle initial, and daytime phone number, along with their full address (city, state, and zip code).
3. Indicate whether you would like your payments to be deducted from your checking or savings account by checking the appropriate option.
4. For checking accounts, provide the routing transit number and account number; for savings accounts, simply provide the account number.
5. If the applicant is different from the person to be billed, please provide the applicant's name and their Blue Cross Blue Shield of Arizona ID number.
6. Remember to review the authorization statement. You must sign and date the form to validate it.
7. Mail or fax the completed form to Enrollment Services, Blue Cross Blue Shield of Arizona, P.O. Box 13466, Phoenix, AZ 85002-3466, or Fax (602) 864-4041.
8. After submitting the form, you can save changes, download a copy, or share it if necessary.

Complete your Surepay Online authorization form today for efficient premium payments!