Get Draft Form

This guide provides a comprehensive overview of how to fill out the Draft Form online, ensuring you navigate each section with clarity and confidence. Completing this form successfully will help you set up your automatic bank draft with Health Net Life Insurance Company.

Follow the steps to complete the Draft Form online:

1. Press the ‘Get Form’ button to access the Draft Form and open it in the designated online editor.
2. Begin by entering your Subscriber/Reference ID number in the appropriate field to help identify your account.
3. Fill in your Medicare claim number, which will assist in linking your draft to your Medicare account.
4. Input your last name, first name, and middle initial in the respective fields.
5. Provide your complete street address, along with your city, state, and ZIP code.
6. Enter your home telephone number in the format (###) ###-####.
7. In the billing information section, if different from the subscriber’s details, enter the account holder's name and address, including city, state, and ZIP code.
8. Input the account holder's telephone number if it differs from the subscriber's.
9. Indicate the type of bank account you wish to use by selecting either 'Checking' or 'Savings'.
10. Enter the transit routing number and account number as provided on your bank documents.
11. Specify the bank name, city, state, and ZIP code related to the account being used.
12. Affirm your authorization by placing your signature in the designated area, showing your consent for automatic withdrawals.
13. Include the date next to your signature to validate the authorization.
14. If necessary, provide an additional signature in the space provided, along with the date.
15. Attach a voided bank check to the form, which will assist in verifying your bank information.
16. After completing all sections, you can proceed to save the changes, download a copy of the form, print it, or share it as needed.

Complete your Draft Form online and ensure your payments are set up effortlessly.