As stated in the Simplepay Health Plan Participant Agreement you signed when enrolling in your employer’s Simplepay Health plan, by submitting this Revocation of HSA Auto-Pay Authorization (“Revocation”), you agree (1) to provide an alternative form of payment (bank account, credit card, or debit card) to Simplepay Health, (2) that such alternative payment method may be automatically charged your cost-sharing amounts due in full on a monthly billing cycle (approximately the 10th of each month), and (3) that the Plan and Simplepay Health and its vendors are not liable for any additional fees charged to you by your banking institution, such as interest or overdraft fees.

Failure to complete this Revocation with complete and accurate information and provide an alternative form of payment will result in your HSA Auto-Pay Authorization remaining in full force and effect.

In the event your alternative form of payment fails when charged, your revocation will be void and your HSA Auto-Pay Authorization will immediately and automatically go back into effect.

Any failure to pay cost-sharing amounts due may result in late fees and Simplepay Health forwarding your account to collections. >

Primary Insured First Name

Primary Insured Last Name

Primary Insured Date of Birth Date format - MM/DD/YYYY

Primary Insured Last 4 of SSN

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Bank Account Debit/Credit Card