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).

Need help?

Visit our Contact Us section for employers.