authorization agreement for preauthorized credit card payments
950 N. Meridian St., Suite 200. Indianapolis, IN 46204-1404. NAME: MEMBERSHIP NO.: I (we) hereby authorize Indiana University Health Plans herein after call ...
AUTHORIZATION AGREEMENT FOR PREAUTHORIZED CREDIT CARD PAYMENTS HOW DO I ENROLL? (Follow these easy steps): 1. Complete the Authorization Agreement for Preauthorized Credit Card Payments form (below). 2. Include your cardholder name, account number, expiration date and V (verification) code. 3. Select the month to begin your monthly withdrawal. (All withdrawals are done on the 1st business day of each month). 4. We ONLY accept VISA, Mastercard and Discover 5. Sign and date your form. 6. Return the form to: Indiana University Health Plans, Inc. Attention: Premium Billing Department 950 N. Meridian St., Suite 200 Indianapolis, IN 46204‐1404
NAME: MEMBERSHIP NO.: I (we) hereby authorize Indiana University Health Plans herein after call COMPANY, to initiate debit entries to my (our) Account indicated below, to debit the same to such account for monthly plan premiums. CARDHOLDER NAME: ACCOUNT NO. : |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| EXPIRATION DATE (MM/YY) : |___|___|___|___| V CODE : |___|___|___| BILLING ADDRESS : (only street #) |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__ ZIP CODE : |___|___|___|___|___| MONTH TO BEGIN WITHDRAWAL: (January – December) ST DAY OF MONTH FOR WITHDRAWAL : __1 BUSINESS DAY OF MONTH (Please allow a minimum of 45 days for processing time) This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY a reasonable opportunity to act on it. NAME(S) SIGNED SIGNED DATE DAYTIME PHONE NO. For Company Use Only: System updated ______________ By ______________________ H7220_IUHMA17004 CMS File & Use 8/6/2016
ATTENTION: Our Customer Solutions Center has free language interpreter services available for non-English speakers. Call 800.455.9776 (TTY: 800.743.3333). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800.455.9776 (TTY: 800.743.3333). 注意:如果您使用 繁體中文,您可以免費獲得語言援助服務。請致電 800.455.9776 (TTY: 800.743.3333). IU Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. IU Health Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. IU Health Plans 遵守適用的聯邦民權法律規定,不因種族、膚色、民 族血統、年齡、殘障或性別而歧視任何 人。
6 ago. 2016 - I (we) hereby authorize Indiana University Health Plans herein after call COMPANY, to initiate debit entries to my (our) Account indicated below, ...
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