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Automatic Payment Plan Enrollment Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you have an individual and family health care plan with us, use this form to have your premium payments automatically deducted from your personal checking or savings account.

What you’ll need:

  • Your enrollee ID card
  • A blank, voided check for the account from which you want to withdraw your payments
  • A printer to print the form
  • An envelope and postage to mail the form, or a fax machine. Each form includes instructions on where to send it.
help-routing-number

Did you know? The form asks for a nine-digit ABA/routing number. That number identifies the name and location of your bank. You can find it at the bottom left corner of your checks.

If you have any questions, please contact us.

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