Get Registration For Preauthorized Monthly Payment Alberta Blue Cross Non-group Coverage Section A Plan

This guide provides clear, step-by-step instructions for successfully completing the Registration for Preauthorized Monthly Payment form for Alberta Blue Cross Non-Group Coverage. Whether you are new to online forms or just need a refresher, this resource will help you navigate the process with ease.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. In Section A, input your personal information: start with your last name, followed by your first name, and your personal health number (PHN). Ensure all details are accurate.
3. Next, provide your mailing address, which includes the city/town and province. Don't forget to include your home phone number to ensure you can be contacted if necessary.
4. Move to Section B, which requires information about the bank account holder. You can specify if the bank account holder’s information is the same as the plan member’s by selecting 'yes' or 'no.' If different, fill out the account holder’s name, phone number, and address including postal code.
5. Enter the name of your financial institution, the branch transit number, and the financial institution number. This information is crucial for the automatic payment process to function correctly.
6. Provide the bank account number associated with the financial institution, as well as the branch address and city/town. Again, make sure to include the corresponding postal code.
7. For verification, you must attach a blank cheque marked 'VOID.' If a cheque is unavailable, have a representative from your financial institution certify the information provided, including their signature and stamp.
8. In Section C, select a preauthorized payment withdrawal date – either the 1st or the 15th of each month. Note that premium statements will not be sent if registered for preauthorized payments.
9. Lastly, in Section D, the bank account holder must sign and date the authorization statement, acknowledging the terms and conditions set forth by Alberta Blue Cross. If applicable, a co-holder must also sign.
10. After filling out all sections accurately, you may save changes, download, print, or share the form as needed.

Complete your documents online and ensure your coverage is set up smoothly.