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Automatic bill payment enrollment form


You can set up an automatic monthly electronic fund transfer (EFT) to pay your monthly premiums by filling out a form, below. Here's how it works.

When your payment is transferred: On the 1st or 10th day of the month, we will automatically debit the checking or savings account that you name on the form. You will no longer get a bill by mail each month.

To set up EFT premium payments: Send us an EFT request form by the 25th day of the month. Automatic premium payments will start on the first of the upcoming month.

To cancel EFT premium payments: We need 30 days advance notice. Send your notice to: Priority Health, MS 1190, 1231 East Beltline NE, Grand Rapids, MI 49525.

Note: We charge $30.00 each time a transfer is not completed due to insufficient funds in your bank account.

Sign up now

Automatic Bill Payment Form - online (see below)
Type in your information, print for your records, and click Submit. It will automatically send to Priority Health.

Automatic Bill Payment Form (PDF) - paper form
Type in your information, print and mail it to us.

Personal info
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Your group number appears on your ID card.
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Financial info
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Transfer date:

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Account type:


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To find your routing number use the 9 digits on bottom left-hand corner of a check, or call your financial institution.
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Your account number follows the routing number on the bottom of your checks.
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Authorization
E-signature:
Print

WARNING: Print this form now.
You will not be able to print it after you click "Submit."