Kaiser Permanente – Member Services Call Centers (OPI)

ACH

[Customer Name], I want to confirm that today [Today’s Date] you are authorizing Kaiser to initiate recurring debits to the Payment Account ending in [XXXX] for the payment due each month as of the Premium Due date or the monthly due date that you have selected (or within 1 to 2 business days before or after that date). The payment amount you are authorizing will never be more than the Total Balance Due on your monthly premium statement but may vary from month to month depending on whether you owe the Total Balance Due or a lesser amount that reflects payments made by you and/or credits to your account that are posted at least 48 hours before your Payment Account is debited. You understand and agree that you are authorizing these varying payments, and the monthly premium statement will be the only notice of the maximum debit to your Payment Account. You understand that if the automatic debit transaction fails (such as no funds are available), you will be responsible for the same $20 minimum returned item service fee that your bank charges from your account. This authorization will remain in effect until you notify Kaiser by contacting Customer Service or by logging into your profile and cancelling or modifying the recurring schedule, and Kaiser and your financial institution have had a reasonable opportunity to act upon your cancellation request. Please say “I agree” to authorize this schedule. [Member must respond]

Credit Card

[Customer Name], I want to confirm you are authorizing Kaiser to initiate recurring charges to the credit card ending in [XXXX] for the payment due each month. The payment amount you are authorizing will never be more than the Total Balance Due on your monthly premium statement but may vary from month to month depending on whether you owe the Total Balance Due or a lesser amount that reflects payments made by you and/or credits to your account that are posted at least 48 hours before your credit card is charged. You understand and agree that you are authorizing these varying payments, and the monthly premium statement will be the only notice of the maximum debit to your credit card. You understand your credit card will be charged as of the Premium Due date or the monthly due date that you have selected (or within 1 to 2 business days before or after that date). This authorization will remain in effect until you notify Kaiser by contacting Customer Service or by logging into your profile and cancelling or modifying the recurring schedule, and Kaiser and your financial institution have had a reasonable opportunity to act upon your cancellation request. Do I have your authorization to submit this request to setup future card charges to your account? [Member must respond]