Get Tricare Prime Eft Or Rcc Request Form - Health Net Federal ... - Hnfs

This guide provides detailed instructions for filling out the TRICARE Prime EFT or RCC Request Form online. By following these steps, users can ensure that their automated payment setup is completed efficiently and accurately.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Read the privacy act statement carefully to understand how your personal information will be used and the authority under which it is collected.
3. In the 'Sponsor Information' section, enter the sponsor's name and Social Security Number accurately.
4. Select the action requested by choosing one of the options: 'START a monthly payment option', 'CHANGE my existing authorization', or 'STOP my existing authorization'.
5. If you are setting up an Electronic Funds Transfer (EFT), provide the account holder's name, the financial institution's name, the nine-digit bank or ABA routing number, and the account number.
6. If selecting Recurring Credit Card (RCC), fill out the cardholder's name, card number, expiration date, and the card validation number.
7. In the signature section, sign to authorize Health Net to initiate the payment method chosen and read the acknowledgment regarding administrative fees.
8. Submit the completed form by mailing it to the appropriate address based on whether you are a new or existing enrollee.
9. Once submitted, ensure to save a copy of the form and any confirmation related to your request. Users may also be prompted to download or print a copy.

Complete your TRICARE Prime EFT or RCC Request Form online today to ensure timely processing of your automated payment setup.