Automatic Payment Forms
Who is this for?
If you want to have your Medicare plan payment automatically deducted from your bank each month, use this form to tell us.
Don't want to worry about remembering to pay your bill? Interested in saving a little money on checks and stamps?
Have your monthly payment for your plan automatically deducted from your bank account. It's safe and secure. If you didn't set up automatic payments when you first enrolled, you can do it at any time using these forms. You'll need:
- Your Blues ID card.
- Your bank's name.
- The number of the account you want to use for the payments.
- Your bank's routing number, shown below.
- A voided check if you're using a checking account, or if you're using a savings account, a deposit slip with your account number on it.