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Thank you for signing the financial agreements! Next, add a payment account to your payment profile.

Paytient’s banking lendors require each plan member have an account on file to pay at least the minimum monthly financing payment on a monthly basis. Once you add an account, you can use it to set up an automatic payment plan to eliminate the worry of having to remember a monthly payment. Adding an account to your payment profile is necessary to enroll and be eligible for the health plan.

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

That this payment method may be automatically charged your selected cost-sharing amount each month, 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 "Credit/Debit Card" option, you agree:

That this payment method may be automatically charged your selected cost-sharing amount each month, 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 "HSA/FSA" option, you agree:

That this payment method may be automatically charged your selected cost-sharing amount each month, 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.
To provide a backup card or bank account as well, in case your HSA/FSA card runs out of funds, or while you are waiting on your HSA/FSA card. Once you have received your HSA/FSA card, you can log into the member portal and add it as your default payment account, or complete this form again.

HSA

FSA

I don’t have my card yet

Name on Card

Card Number

CVC

Exp. Month

Exp. Year

Address 1

Address 2

City

State

Zip Code

HSA/FSA cards are a great way to pay cost effectively for healthcare, but they have account limits, or you might not have your card yet. Please add a different card or bank account to your profile to support you until you receive your HSA/FSA card, or if your HSA/FSA card is no longer an available option.

Debit/Credit Card

Bank Account

Debit

Credit Card

Name on Card

Card Number

CVC

Exp. Month

Exp. Year

Address 1

Address 2

City

State

Zip Code

Routing Number

Name on Account

Account Type

Checkings

Savings

Account Number

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