Sign up for autopay

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Member Name* This field is required.

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Member Number (found on your ID card)* This field is required.

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Name of Bank* This field is required.

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Name on Account* This field is required.

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Bank Address

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Account Holder's Address: if different than Member's, check here.

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Account Holder's Address

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Account Holder's Email Address (required for APO)

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Account Holder's Email Address* This field is required.

example@example.com

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Routing Number* This field is required.

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Account Number* This field is required.

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Account Number* This field is required.

Checking Account

Savings Account

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1.By setting up automatic payments, I authorize Florida Blue to initiate recurring debits or card payments from my account provided. To sign up for APO using credit or debit card, please log in to your member account or call the phone number listed on the back of your ID card. 2. The amount debited each month will be the current payment amount due. 3. All recurring payments will be automatically withdrawn each month on the due date as indicated on my monthly billing statement. 4.This agreement will remain in effect until canceled by me or my coverage is canceled. | understand | can terminate this authorization at any time by calling Florida Blue at 1-800-352-2583. 6. By providing my email address, I agree to receive monthly emails about my automatic payments. By signing below, I agree to the above Terms and Conditions.

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Signature* This field is required.

Clear

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Date* This field is required.

Date

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Health insurance is offered by Florida Blue. HMO coverage is offered by Florida Blue HMO, an affiliate of Florida Blue. Dental insurance is offered by Florida Combined Life Insurance Company, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-352-2583 (TTY: 1-877-955-8773 ATANSYON: Si W pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-800-352-2583 (TTY: 1-800-955-8770