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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.

If your bank account does not have sufficient funds to cover your plan’s premium payment, Priority Health reserves the right to charge a non-sufficient funds (NSF) fee up to the amount allowed by the state of Michigan, which is $25.

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."