Edit, Download, and Sign the One-Time eCheck Payment Authorization Form
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How do I fill this out?
To fill out this form, gather your personal and bank account information. Carefully read the instructions on the form. Ensure that all required fields are completed accurately before submission.
How to fill out the One-Time eCheck Payment Authorization Form?
1
Gather your account holder name and billing address.
2
Fill in your bank routing and account numbers.
3
Specify the authorized amount for the eCheck payment.
4
Sign the form to authorize the one-time payment.
5
Submit the completed form via mail or fax.
Who needs the One-Time eCheck Payment Authorization Form?
1
Individuals making a one-time health insurance payment.
2
Businesses needing to process an employee's health benefit payment.
3
Healthcare providers that require upfront payment for services.
4
Insurance agents assisting clients in making payments.
5
Financial departments needing to document one-off transactions.
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What are the instructions for submitting this form?
Submit the completed authorization form by mailing it to: Western Health Advantage, Attn: Sales, 2349 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833. Alternatively, you can fax it to 916.568.1338. For any questions regarding submission, please call 916.563.3198 or 888.499.3198 (toll-free). Ensure your form is filled out completely and accurately for prompt processing.
What are the important dates for this form in 2024 and 2025?
For 2024, ensure all payments are submitted by January 15th for timely processing. In 2025, similar deadlines should be expected around the same dates.
What is the purpose of this form?
The primary purpose of this form is to authorize a one-time eCheck payment for health insurance services. It facilitates secure transactions by allowing Western Health Advantage to debit the specified amount directly from the applicant's bank account. This ensures a streamlined process for both consumers and healthcare providers.
Tell me about this form and its components and fields line-by-line.
- 1. Account Holder Name: The name of the individual or entity authorized on the bank account.
- 2. Billing Address: The address where billing correspondence should be sent.
- 3. Bank Routing/Transit #: The first 9 digits of the bank routing number.
- 4. Bank Account #: The subsequent 10 digits of the bank account number.
- 5. Amount Authorized: The total amount being authorized for the one-time payment.
- 6. Authorized Signature: The signature of the individual authorizing the transaction.
- 7. Today's Date: The date on which the form is signed.
What happens if I fail to submit this form?
Failing to submit this form may result in your payment not being processed, leading to potential delays in obtaining health coverage. Additionally, your account may continue to incur charges until the payment is received. It is important to ensure all parts of the form are completed before submitting.
- Delayed Payment: Payments may not be processed on time, affecting your coverage.
- Ongoing Charges: Failure to submit can lead to ongoing payments due to lack of authorization.
- Increased NSF Fees: Not authorizing payment may lead to non-sufficient fund fees.
How do I know when to use this form?
- 1. Health Insurance Payments: To authorize the payment for an insurance policy.
- 2. Coverage Updates: When updating or initiating new health insurance coverage.
- 3. One-Time Transactions: When you need to make a unique payment without future obligations.
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