Get Automatic Payment Authorization Form - Wellmark Blue Cross And ...

Filling out the Automatic Payment Authorization Form is a crucial step for ensuring your payments to Wellmark Blue Cross and Blue Shield are made effortlessly on time. This guide provides comprehensive instructions to assist you in completing the form online with confidence.

Follow the steps to complete the form efficiently.

1. Use the ‘Get Form’ button to access the Automatic Payment Authorization Form and open it in your preferred document editor.
2. Begin by providing your personal information in the designated fields. This includes your name, address, date of birth, and Wellmark Social Security Number or ID.
3. Next, enter the financial institution name along with the name of the bank account holder. Ensure that the information matches the records held by your bank.
4. Select your desired payment frequency by choosing one of the options provided: monthly, quarterly, semi-annually, or annually. You will also need to pick a specific day of the month for withdrawals, such as the 1st or 5th, unless you have COBRA premiums which are set to monthly.
5. Indicate whether the account type is checking or savings. If using a savings account, remember to include a voided deposit slip instead of a check.
6. Fill in the state code, routing number, and bank account number as indicated. If you are unsure where to find this information, refer to the instructions provided in the form.
7. To finalize your authorization, provide your signature and the date. Ensure that both pages of the form are completed as required.
8. You can now save your edits, download, print, or share the completed form as needed. When submitting, return both pages via fax or mail to the provided addresses to avoid any delays.

Complete your Automatic Payment Authorization Form online today for hassle-free payments!