TEST - ICHRA EFT Cancellation Request Form

*Required fields

This form is for ICHRA agencies to submit a request for Electronic Funds Transfer (EFT) cancellation on behalf of a member enrolled in an Individual Coverage Health Reimbursement Arrangement (ICHRA) plan.

Important information prior to submission:

  • This form does not cancel the member’s policy. If the member wishes to continue their coverage, they must make future payments manually or resubmit an EFT authorization.
  • This form should only be submitted by an ICHRA agency. If you are a broker, please contact Agent Support for guidance on EFT cancellations.
  • If the member wants to cancel their policy or cancel their EFT authorization, they should call the number on the back of their ID card.

ICHRA Agency Information

Member Information

Please enter a valid Date, mm/dd/yyyy
Please enter a valid Date, mm/dd/yyyy

Review and Sign

Agency Name : Edit
Agency Number : Edit
Agent Number : Edit
Member First Name : Edit
Member Last Name : Edit
Member Date of Birth : Edit
Member Social Security Number (optional) : Edit
Member's Employment Status Change Reason : Edit
Member's Cancel Date : Edit
BCBSND Bill Account Number (optional) : Edit

Agent Signature

By checking this box, Inderstand I am creating an electronic signature that carries the same legal obligations as a written signature and am agreeing to all of the terms and conditions set forth within this request.

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