Kaiser Permanente: Electronic Funds Transfer Authorization Form

Electronic Funds Transfer Authorization Form
To start this service, please:
1. Complete and sign this form.
2. Remove the form from this booklet and return it with a preprinted, voided check to ensure accurate account information.
3. Mail to: Kaiser Foundation Health Plan of the Northwest, P.O. Box 203007, Denver, CO 80220-9007; or fax to 866-846-2650.
Submit this form only once, unless your financial account information changes.
If you have already signed up for electronic funds transfer, you do not need to complete and return this form.
Please continue to send in your monthly payment until you are notified by mail of the start date for electronic funds transfer.
After we receive your completed authorization form, please allow 30 days for processing. Items returned by your financial
institution are subject to a $25 processing fee. If you have any questions, please call us toll free at 1-866-291-4010.
Representatives are available 8 a.m. to 5 p.m., Monday through Friday (except holidays).
Fill in all areas below.
Subscriber’s name
Subscriber’s health record number
Subscriber’s address
City
Financial institution
Routing number (9 digits)
Bank account holder’s name(s)
Checking or savings account number (circle one)
State
ZIP
X
Subscriber’s signature — required (Use black ink only.)Date
For savings or credit union accounts, please obtain the routing number from your financial institution. Attach a preprinted, voided
check to this form (see below) or include a letter from your financial institution that includes the routing number, account number,
account type (checking, savings, etc.), and bank account holder’s name. Deposit slips cannot be accepted.
Authorization agreement: I authorize Kaiser Foundation Health Plan of the Northwest (KFHPNW) and the designated financial
institution to initiate monthly transfers from my checking or savings account to pay my Health Plan premium as indicated by
KFHPNW. I understand that it is my responsibility to notify KFHPNW of any changes to my bank account and that I can terminate
the electronic funds transfer process with a 30-day written and signed advance notice.
X
Bank account holder’s signature required (As shown on financial records. Use black ink only.)Date
Please tape down all four corners of the preprinted, voided check here.
If you would like to have your premiums withdrawn from your savings account,
please include a letter from your bank with routing and account information.
Deposit slips cannot be processed.
Do not put credit card information on this form.
60315711 Northwest 2016