SAVE TIME
WITH PAYMENT
OPTIONS THAT
MEET YOUR NEEDS
Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit
independent licensees of the Blue Cross and Blue Shield Association
This information is available in other ways for people with disabilities or who
need it translated into another language by calling 1-800-382-2000 (toll free).
For TTY, call 711.If you want free help translating this information, call the
above number.Si desea ayuda gratis para traducir esta información, llame
al número que aparece arriba.
8/16
F10597R02
CS205904
bluecrossmnonline.com
YES,
SIGN ME
UP FOR PAYITEASY
PREMIUM
NO MORE
WRITING
A CHECK FORAUTOMATIC
YOUR PREMIUM
PAYMENT
PROGRAM
PAYMENT...OR GOING TO THE POST OFFICE FOR
•STAMPS...OR
I hereby authorize
Cross TIME
and Blue
TAKING Blue
VALUABLE
OUT Shield
OF
of
Minnesota
(Blue
Cross)
and
the
financial
YOUR DAY TO PAY YOUR BILL IN PERSON.
institution designated to begin deductions
for my premium payment.
• I authorize
the financial
to charge
OPTION
1: ONLINEinstitution
EBILL PAYMENT
these withdrawals to my account. I understand
that
I may
discontinue
my participation
Our
e-Bill
option
is available
through our with
written
or oral website.
notice toSwitching
Blue Cross.
secure
member
to online
Click “Submit.”
PAYITEASY
FORM
PLEASE
PRINT
4.
Follow
the directions to make your
payment arrangements. If your invoice
________________________________________
is not displayed on the “Current Invoice”
Membership ID Number (As it appears on your ID card)
screen, click on the ”Invoice History” link.
________________________________________
Please note: The payment must match
Name of Member
the full invoice amount.
________________________________________
Address
CHECK OUT “FREQUENTLY ASKED QUESTIONS”
my Blue
premium
until I am
Online
e-BillCross
payment
gives as
youusual
freedom
notified
that my automatic bank account
and
flexibility:
is beginning.
• deduction
Make a one-time
payment while you are
temporarily away from home.
ON YOUR WEBSITE
________________________________________
City questions about whenState
Zip be
Have
your bill will
available to pay…how to set up recurring
(________)______________________________
payments…how
to receive
Area Code
Telephone
Number paper bills again. . .
how to change your bank account information?
________________________________________
Look
for the “Help” link after you log in to your
Email address
member site and click “Pay my premium”.
________________________________________
Name(s)questions
Account (If different
from person
listed above)
Have
or need
help setting
up
your e-Bill payment? Call the customer
________________________________________
service
number
on the back of your ID card.
Name of Financial
Institution
•
Make recurring
payments
months.
ATTACHED
FORM. PLEASE
MAKEover
SUREseveral
THAT YOU…
________________________________________
payment
allows
you
to have
your
•e-Bill
I also
understand
that
both
the financial
premium
automatically
deducted
your to
institution
and Blue Cross
reservefrom
the right
account.
Many
already
enjoy
this my
terminate
thispeople
payment
program
and/or
convenient
method
paying their electric,
participation
in thisfor
program.
gas
and
credit
card
bills.
• I understand that I must continue to pay
TO ENROLL IN PAYITEASY, FILL OUT AND RETURN THE
• Receive
anname
e-mailand
reminder
before
1.
Sign your
date this
formyour
where
payment
is
deducted
from
your
account.
indicated. (Account holder must sign, too, if
different
• View
and from
print member.)
your current or past bills.
2.
Enclose
a voided
withinformation.
your address on it.
• Easily
update
yourcheck
account
3. Make a copy of this form for your records.
4. Mail your completed form and voided check with
IT’S EASY TO GET STARTED OR SWITCH TO EBILL:
your next bill or enrollment application to:
1. Go
www.bluecrossmnonline.com
BluetoCross
and Blue Shield of Minnesota
2. Select
login
andSt.
enter
and
P.O. Box 64560,
Paul,your
MN username
55164-0560
(If you
need to register, select the
5. password.
Fax a copy to:
651-662-6439
Register link and follow the directions.)
3. After you’re logged in, click “Pay monthly
premium” in “Health Care Tools”. Complete
the one-time
Registration”
by
If you have“e-Bill
questions,
call the customer
providing
your
billing
ID
number
from
service number on the back of your
ID card.
your paper invoice.
Checking/Saving Account Number
____ Checking
_____Savings
________________________________________
Bank Routing Number
I authorize my bank account to be debited for the account(s) below
(check all that apply, if not checked we will assume all apply)
__ Health Plan Bill Account
__ Dental Plan Bill Account
________________________________________
Signature of Account Holder
________________________________________
Signature of Legal Guardian or Power of Attorney (If applicable*)
________________________________________
Date
* If you have a representative acting for you, include a copy of your Power
of Attorney or proof of legal guardianship if it is not already on file with us.
OPTION 2: PAYITEASY
PAYITEASY
If you don’t have access to the Internet, consider
our Pay-It-Easy® option. With Pay-It-Easy, you
can still enjoy the convenience of having your
premium payment automatically deducted
from your bank account each month. You will
need to submit a paper form.
HOW IT WORKS: COMMONLY ASKED QUESTIONS How
will I know when my first payment is being
deducted from my bank account?You will
receive a letter in the mail that informs you
when your first payment will be deducted.
Your monthly bank statement will note the
date and show the amount of your future
premium.
Be sure to continue to pay your health
premium as usual until you are notified
that automatic payment has begun.
What happens if I do not have enough
money in my bank account on that date?
Your bank will notify us and may then charge
you a penalty for insufficient funds. You also
will be removed from the Pay-It-Easy
Premium Payment Program and receive
paper bills. You will need to re-enroll if you
want this payment option in the future.
If my spouse is a member under a separate
policy and wants to participate, can we use
the same Pay-It-Easy form?
No. Please complete a separate Pay-It-Easy
Form for each policy.
What if I later decide Pay-It-Easy is
not for me?
Just send us a letter or call the customer
service number on the back of your ID card. In
general, if we receive your request by the 15th
of the month, the next invoice will not be
withdrawn from your account. Instead, we
will send you a regular paper bill.
Please note: Outstanding invoice(s) will
continue to be drawn from your account.
You will need to complete and return a new
Pay-It-Easy form along with a new voided
check if…
• You change to another Blue Cross program
• Change banks or your bank account numbers
YES,MORE
SIGN ME
UP FOR PAYITEASY
PREMIUM
NO
WRITING
A CHECK FORAUTOMATIC
YOUR PREMIUM
PAYMENT
PROGRAM
PAYMENT...OR GOING TO THE POST OFFICE FOR
•
I hereby authorize
Cross TIME
and Blue
STAMPS...OR
TAKING Blue
VALUABLE
OUT Shield
OF
of
Minnesota
(Blue
Cross)
and
the
financial
YOUR DAY TO PAY YOUR BILL IN PERSON.
institution designated to begin deductions
for my premium payment.
• I authorize
the financial
to charge
OPTION
1: ONLINEinstitution
EBILL PAYMENT
these withdrawals to my account. I understand
that
I may
discontinue
my participation
Our
e-Bill
option
is available
through our with
written
or oral website.
notice toSwitching
Blue Cross.
secure
member
to online
Click “Submit.”
PAYITEASY
FORM
PLEASE
PRINT
4.
Follow
the directions to make your
payment arrangements. If your invoice
________________________________________
is not displayed on the “Current Invoice”
Membership ID Number (As it appears on your ID card)
screen, click on the ”Invoice History” link.
________________________________________
Please note: The payment must match
Name of Member
the full invoice amount.
________________________________________
Address
CHECK OUT “FREQUENTLY ASKED QUESTIONS”
my Blue
premium
until I am
Online
e-BillCross
payment
gives as
youusual
freedom
notified
that my automatic bank account
and
flexibility:
is beginning.
• deduction
Make a one-time
payment while you are
temporarily away from home.
ON YOUR WEBSITE
________________________________________
City
Zip be
Have questions about whenState
your bill will
available to pay…how to set up recurring
(________) ______________________________
payments…how
to receive
Area
Code
Telephone
Number paper bills again. . .
how to change your bank account information?
________________________________________
Look for the “Help” link after you log in to your
Email address
member site and click “Pay my premium”.
________________________________________
Name(s)
Account (If different
from person
listed above)
Have questions
or need
help setting
up
your e-Bill payment? Call the customer
________________________________________
service
number
on the back of your ID card.
Name
of Financial
Institution
•ATTACHED
Make recurring
payments
months.
FORM. PLEASE
MAKEover
SUREseveral
THAT YOU…
________________________________________
e-Bill
payment
allows
you
to have
your
• I also
understand
that
both
the financial
premium
automatically
deducted
your to
institution
and Blue Cross
reservefrom
the right
account.
Many
already
enjoy
this my
terminate
thispeople
payment
program
and/or
convenient
method
paying their electric,
participation
in thisfor
program.
gas
and
credit
card
bills.
• I understand that I must continue to pay
TO ENROLL IN PAYITEASY, FILL OUT AND RETURN THE
•1. Receive
anname
e-mailand
reminder
before
Sign your
date this
formyour
where
payment
is
deducted
from
your
account.
indicated. (Account holder must sign, too, if
different
• View
and from
print member.)
your current or past bills.
Enclose
a voided
withinformation.
your address on it.
•2. Easily
update
yourcheck
account
3. Make a copy of this form for your records.
4. Mail your completed form and voided check with
IT’S EASY TO GET STARTED OR SWITCH TO EBILL:
your next bill or enrollment application to:
1. Go
www.bluecrossmnonline.com
BluetoCross
and Blue Shield of Minnesota
2. Select
login
andSt.
enter
and
P.O. Box 64560,
Paul,your
MN username
55164-0560
(If you
need to register, select the
5. password.
Fax a copy to:
651-662-6439
Register link and follow the directions.)
3. After you’re logged in, click “Pay monthly
premium” in “Health Care Tools”. Complete
the one-time
Registration”
by
If you have“e-Bill
questions,
call the customer
providing
your
billing
ID
number
from
service number on the back of your
ID card.
your paper invoice.
Checking/Saving Account Number
____ Checking
_____Savings
________________________________________
Bank Routing Number
I authorize my bank account to be debited for the account(s) below
(check all that apply, if not checked we will assume all apply)
__ Health Plan Bill Account
__ Dental Plan Bill Account
________________________________________
Signature of Account Holder
________________________________________
Signature of Legal Guardian or Power of Attorney (If applicable*)
________________________________________
Date
* If you have a representative acting for you, include a copy of your Power
of Attorney or proof of legal guardianship if it is not already on file with us.