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Check It Out

Pay premiums automatically from your bank account.

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Required fields are noted with an asterisk *.

* Reason for submitting form

Subscriber Information
* Subscriber's Full Name		* Identification Number (as it appears on the ID card)	* Daytime Telephone Number

Address Information
* Street Address
* City	* State	* ZIP Code
* Is this a new address?

Financial Institution Information
* Account Type

* Name of Financial Institution	* ABA Number	* Confirm ABA Number
* Name on Bank Account	* Bank Account Number	* Confirm Bank Account Number
* Signature of Capital BlueCross subscriber
Signature if account is other than subscriber's		Date

By completing this form, I/we authorize Capital BlueCross and its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^®, Keystone Health Plan Central^®, and the financial institution named above, to deduct the amount of the premium for health care coverage from my/our account on the designated day and transfer such amount directly to Capital BlueCross.

If the designated day is a holiday, the premium payment will be deducted on the next business day.

I/we agree to maintain sufficient funds in the account to permit these deductions. If the account does not have sufficient funds at the time of transfer, I/we understand that my/our Capital BlueCross health care coverage may be canceled.

By typing my full name below and submitting this form, I understand that I am creating an "Electronic Signature" that carries the same legal obligations of a written signature name.

* Authorized Signature (acts as electronic signature)

* Date Submitted

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Clicking 'submit' certifies the information provided is true and correct.

CMS Tracking DnD

Updated October 1, 2018

Y0016_WBST19