Group Authorization Agreement for Automatic Payments Form

Who is this for?

Use this form to set up automatic payments for your group health care plan.

If you offer a Blue Care Network employer-sponsored health care plan, use this form to set up automatic payments. 

Want the convenience of having the premiums for your employer-sponsored health care plans through Blue Care Network paid automatically? 

Just download, complete and send us the Authorization Agreement for Automatic Payments (PDF).

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Visit our Contact Us section for employers.

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