Quality health plans & benefits
Healthier living
Financial well-being
Intelligent solutions
Easy Pay from Aetna
Enjoy the ease of automatic bill paying
You can save time and money and never miss a payment. Easy
Pay from Aetna automatically withdraws your plan premium
payment from your checking account on the date it is due.
You don’t have to spend a cent on checks, envelopes and
postage. Plus, you don’t have to worry about your payment being
late or getting lost in the mail. And if you like to “go green” (by
not getting a bill in the mail), you can feel good about how much
paper and gas you are saving.
Your payments will appear on your bank statement as
“Aetna Autodebit Coverage.”
Easy Pay takes about 20 days to start. If you get a bill in the mail
before then, please pay by check.
The direct electronic payment of the Aetna plan premium will be
taken from your bank account around the 1st or 15th of every
month depending upon your policy effective date.
Apply today with the form on the back.
Setting up Easy Pay is, well, easy
If you are enrolled in an Aetna plan, you can sign up for
Easy Pay today. Just fill out the form on the back. Then mail
it or fax it to us.
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Questions?
Call 1-866-772-3862. Hearing
impaired call 1-800-628-3323.
Here’s how to apply
1. Fill out the information at right.
2. Mail to:
Aetna
Attn: EFT
P.O. Box 730
Blue Bell, PA 19422
Or fax to:
1-860-975-1253
Member information
Aetna Member ID # _______________________________________________________________________
Name _____________________________________________________________________________________
Address __________________________________________________________________________________
City ______________________________________________________________________________________
State _____________________________________________________________________________________
Zip _______________________________________________________________________________________
Telephone________________________________________________________________________________
To receive confirmation, please share your e-mail address.
E-mail ________________________________________________________________________________
Checking account information:
Name(s) on Checking Account
______________________________________________________________________________________
Checking Account # ___________________________________________________________________
Routing #
❏❏❏❏❏❏❏❏❏
Name of Bank _________________________________________________________________________
IMPORTANT — Please read and sign.
Terms of Authorization: I have an account(s) at the financial institution named and, for all debit entries, have funds sufficient to pay such
entries. Electronic debit entries shall be initiated by Aetna to pay Aetna plan premiums and other charges for the listed health care
policies or other policies as authorized, and the entries shall constitute my receipt for the transaction(s). No payment to Aetna shall be
deemed to have been made unless and until Aetna receives full and final credit for the payment. I also understand that if corrections to
the entry are necessary, they may involve an adjustment to my account. I understand my direct electronic payment of the Aetna plan
premium will be taken from my bank account around the 1st or 15th of every month depending upon my policy effective date.
NOTE: All terms and conditions of the Aetna plan policy shall remain in full force and effect. Aetna reserves the right to refuse or
terminate electronic payment services at any time. This agreement is to remain in effect until Aetna or the member terminates it. For the
termination to be effective and to discontinue electronic withdrawal, the termination notice needs to be received, by Aetna, 10 days
prior to the next scheduled withdrawal.
Joint accounts require the signature of ALL persons having authority over the account. Please be sure all joint account holders
sign below regardless of who is applying.
Signature __________________________________________________________________________________________________________________
Signature __________________________________________________________________________________________________________________
Aetna health insurance plans are underwritten by Aetna Life Insurance Company, directly and/or through an out-of-state blanket trust or group
policy, and/or Aetna Health Inc. (together, “Aetna”). In CT these plan are issued on an individual basis and are regulated as individual health
insurance plans.
www.aetna.com
©2012 Aetna Inc.
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