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It is designed to facilitate the collection of necessary employer information, including group identification and contact details, alongside the required financial institution data for processing one-time debit payments. By completing this form, group representatives authorize MediExcel Health Plan to initiate a debit to their specified bank account, establishing a secure method for payment of health plan coverage. The form includes sections for bank routing and account numbers, account and banking type specifications, and a formal signature section where the authorized representative agrees to the terms and conditions of the payment, including policies regarding returned items and service charges. 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Please complete the requested information and return this form with your completed employer coverage application. Any missing information may delay the processing of your application and/or payment.  \nEmployer Information  \n\n| Group Name: |  |  |\n| --- | --- | --- |\n| Group Number: |  |  |\n| Group Representative Name: |  |  |\n| Group Confirmation Email: |  |  |\n| Group Address: |  |  |\n| City | State | Zip Code |\n\nFinancial Institution Information (Required)  \n\n| Name of Financial Institution: |  |\n| --- | --- |\n| 9-Digit Bank Routing Number: | Total Amount Due: |\n| Bank Account Number: |  |\n| Account Type (Personal/Business ): | Banking Type (Checking/Savings): |\n| Name on the Account: |  |\n\nSignature Required  \nI authorize MediExcel Health Plan to initiate a one-time debit to the bank account shown above. If this item is returned unpaid, I authorize MediExcel Health Plan to mail a bill to the address on record and the group will be responsible for making the payment by check or money order, and for paying any return item service charges in order for coverage to become effective.  \nBy signing this form, I agree to the terms and conditions stated and acknowledge that I have received a copy of this form.  \nGroup Representative Signature Print Name Date  \nPlease retain a copy of this form for your records.","cbCaitof9f5OJ5wv","https://ap.wps.com/l/cbCaitof9f5OJ5wv","pdf",181052,"English","# Employer Information\n# Financial Institution Information\n# Signature Required","[{\"question\":\"What is the purpose of this document?\",\"answer\":\"This document is an Electronic Funds Transfer (EFT) authorization form used by employers to authorize a one-time debit payment from their bank account to MediExcel Health Plan.\"},{\"question\":\"What information is required from the financial institution?\",\"answer\":\"The form requires the name of the financial institution, the 9-digit bank routing number, the bank account number, the account type (personal/business), the banking type (checking/savings), and the name on the account.\"},{\"question\":\"What happens if an electronic payment is returned unpaid?\",\"answer\":\"If the item is returned unpaid, MediExcel Health Plan will mail a bill to the address on record, and the group becomes responsible for paying the balance via check or money order, plus any applicable return item service charges.\"}]","MediExcel Health Plan - Group Initial EFT Payment Form | PDF",1789631608]