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Auto-payment program Account Selection Form

To protect the integrity of your account and meet the requirements for no credit-check, interest-free financing, Simplepay Health requires that you participate in an automatic auto-payment program to pay your SimplePay minimum due amount reported on your monthly statement. The auto-payment program only turns on if you miss making a minimum monthly payment by the statement due date.

Please complete the following fields with the primary plan member’s information, and click Next. You will then be prompted underneath to select your desired payment method for the Simplepay Health auto-payment program. If you participate in the SimplePay plan but fail to select a preferred payment method, or if your form of payment is not accepted, the default payment method will become payroll deductions.

Primary Insured First Name

Primary Insured Last Name

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

Primary Insured Last 4 of SSN

Bank Account Debit/Credit Card Payroll Deduction

By selecting the "Bank Account" option, you agree:

That this payment method may be automatically charged any minimum cost-sharing amounts, that you fail to timely pay and
That your health 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.

If you are making this selection while already in the auto-payment program utilizing payroll deduction, you may still have payroll deductions taken for a period of time. Simplepay Health is unable to stop any payroll deductions that have already been reported to your employer or employer’s payroll administrator for processing.

Failure to complete this form with accurate information and provide a form of payment will result in your payroll deduction authorization remaining in effect. Please note any unresolved failure to pay the minimum cost-sharing amounts due may result in Simplepay Health forwarding your account to collections.

By selecting the "Credit/Debit Card" option, you agree:

That this payment method may be automatically charged any minimum cost-sharing amounts, that you fail to timely pay and
That your health 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.

By selecting the "Payroll Deduction" option:

If you do not pay your Simplepay Health statement minimum by the due date, the SimplePay auto-payment program will automatically begin paying your minimum payments each month through payroll deductions until paid in full.

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