TEST - ICHRA EFT Cancellation Request Form (with agent)

*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 Sales Support for guidance on EFT cancellations.
  • If the member wants to cancel their policy, they should call the number on the back of their ID card. 

ICHRA Agency Information

Agent 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 First Name : Edit
Agent Last Name : 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 Employer Status Change 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.