OHP ACH Form

Here's how the Direct Payment Plan works: You authorize regularly scheduled payments to be made from your checking or savings account. Then, just sit back and relax. Your payments will be made automatically on the 15th of each month. And proof of payment will appear on your statement.

The authority you give to charge your account will remain in effect until you notify us in writing to terminate the authorization. You must notify us in writing within ten (10) days of any change to the dollar amount of your authorization. To take advantage of this service, complete the authorization form and return it to us.

Mark the type of account to indicate whether your payment will be deducted from your checking or savings account.
Fill in your name, financial institution name and location, amount of authorization and date.
If debiting from your checking account, attach a voided check for verification of all financial institution information. If you are unable to attach the voided check, please fill in your account number and routing number. See the example below for where these numbers can be found.
If debiting from your savings account, please verify your routing number and account number with financial institution. your

Please complete the information below.

I authorize the initiate electronic debit entries to my:

Type of account for payment of my Orthodox HealthPlan Premium*

CheckingSavings

I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. This authority will remain in effect until I have cancelled it in writing.

*Each year, your payment will automatically be adjusted for the amount based on the premium for the new plan year.

To stop or change ACH payments from the monthly amount allocated to you, you must return this form. Proof of payment will appear on your bank statement. The authority you give to charge your account will remain in effect until you notify us in writing to terminate or change the authorization. You must notify us in writing within ten (10) days of any change to the dollar amount of your authorization.

INSURED'S NAME *

Clergy or Lay person's Name

FINANCIAL INSTITUTION NAME (PLEASE PRINT)*

NAME(S) ACCOUNT IS LISTED UNDER*

ACCOUNT NUMBER AT FINANCIAL INSTITUTION*

FINANCIAL INSTITUTION ROUTING NUMBER*

FINANCIAL INSTITUTION CITY AND STATE*

SIGNATURE*

If you prefer you can upload your signature file

Date Signed*

Date

Orthodox HealthPlan ACH Authorization Form