The undersigned Foreign Service Benefit Plan Member ("Member") hereby: (1) authorizes Aetna Life Insurance Company and its affiliates (Aetna) to make payments by Electronic Fund Transfer (EFT), (2) certifies that Member has selected the following depository institution, and (3) directs that all such EFT payments be made as provided below. When properly executed, this Authorization will become effective within thirty (30) days after its receipt by Aetna. Member agrees to refund to Aetna any payments made to Member erroneously by Aetna.
Enrollee (Last, First, MI)
Member ID Number (W1234 56789)
Address
City
State
Zip Code
Email Address *
Telephone Number
Bank Name
Type of Account
Routing Number (9 digits)
Account Number
Name on Account
Type
This authorization will remain in effect until Aetna receives notification of termination of this form from the Member. Member will provide thirty (30) days advance notice in writing to Aetna of termination or any changes in the depository institution or other payment instructions. Only one bank account per family is permitted. Before submitting this Authorization Form, Member should check with the banking institution to verify that it will be able to receive Automated Clearing House (ACH) transactions and if there are any associated fees for this service. Member agrees that Aetna will not be responsible for any such fees.
Your Explanation of Benefits (EOB) will be available to you on the Aetna secure member website and will no longer be mailed to you. Please log on to the Aetna secure member website to view your Explanation of Benefits.*
Enrollee's Electronic Signature *
Date (mm/dd/yyyy)
Name
* If you would like to continue to receive a paper copy of your EOB, please check here