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.

Are you submitting an EFT cancellation request for an ICHRA? Yes

ICHRA Agency Information

Agency Name

Agent Information

Agent First Name

Agent Last Name

Member Information

Member Date of Birth

Please enter a valid Date, mm/dd/yyyy

Member Social Security Number (optional)

Member's Employer Status Change Date

Please enter a valid Date, mm/dd/yyyy

BCBSND Bill Account Number (optional)

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

Agent Name

Agency Number

Agency Name

Agent First Name

Agent Last Name

Agent's 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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