Get Auto Pay Request Form - Pacificsource Medicare

Completing the Auto Pay Request Form for PacificSource Medicare allows for convenient monthly withdrawals directly from your bank account. This guide provides clear instructions to help you fill out the form correctly and ensure a smooth process.

Follow the steps to complete your Auto Pay Request Form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in your member information. This includes your full name (First, M.I., Last), member ID, date of birth, and phone number.
3. Read the authorization for automatic deduction section. Understand that monthly withdrawals will occur on the fifth of each month, including any unpaid balances.
4. Indicate your preferred account type for the deductions by selecting either Checking. Remember to attach a voided check, as deposit slips will not be accepted.
5. Sign the form in the Member Signature section and date it. Ensure your signature matches the name provided earlier.
6. If you are not the accountholder, the individual who holds the account must also sign and date the Accountholder Signature section. They should include their full name as well.
7. Once you have completed all sections, review the form for accuracy before saving your changes. You can then download, print, or share the completed form as needed.

Take the next step towards hassle-free payments by completing your Auto Pay Request Form online today.