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Get TX USFHP Enrollment Fee Allotment Authorization Letter

Ish to take for the allotment process. Please mark one of the three boxes and complete the requested information. Please Start a monthly allotment to USFHP from my retirement pay for USFHP enrollment fees in the amount of: $ (Single $22.44 or Family $44.88) I have enclosed a payment (personal check, cashier s check, traveler s check, money order or credit card) for the initial *3-month payment ($67.32 individual or $134.64 family) if required. Please circle card type: Visa / Mast.

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