Authorization Agreement for Automatic Payments Form
Who is this for?
If you're a Blue Care Network member, use this form to have your health insurance payments automatically deducted from your personal checking or savings account.
Access the form here: Authorization Agreement for Automatic Payments Form (PDF)
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.
Mail the form to:
Blue Care Network
IAA/Billing Department - Mail Code C415
P.O. Box 5043
Southfield, MI 48086
If you have any questions, please contact us.