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Electronic Funds Transfer (EFT) 2009 Authorization Form

Take advantage of a safe, convenient, automatic premium payment option called Electronic Funds Transfer, or EFT. With EFT, your monthly payment will be automatically deducted from your checking account on or around the fifth of every month and forwarded to the plan by your bank or financial institution.

EFT saves you time and money:

· You don't have to write out a check and mail it each month. · You save on the cost of stamps and don't have to use your checks.

Plus, EFT helps bring you peace of mind:

· Your payments are made through secure electronic transactions. · You won't have to remember to mail your premium if you travel or become ill. · Your check will never be delayed or lost in the mail.

Signing Up For EFT Is Easy!

It takes just a few minutes to set up your monthly premium payment on EFT. All you have to do is:

1. Complete the Authorization Form below. 2. Write "VOID" on a check from the account you would like the EFT payments withdrawn from.

Do NOT send a deposit slip or cancelled check.

3. Return the completed Authorization Form and voided check to AARP MedicareRx Plans,

P.O. Box 29300, Hot Springs, AR 71903-9300. Once your completed form is processed, you will be notified by mail of the date your EFT begins. You should continue to pay your monthly premium using your current payment method until that time. M Detach & mail with voided check M

Electronic Funds Transfer EFT Authorization Form

I authorize United HealthCare Insurance Company (United HealthCare Insurance Company of New York for New York residents) insurer of the AARP MedicareRx Plans to initiate monthly withdrawals, in the amount of my current monthly premium, from the account named on this form and authorize the named banking facility (BANK) to charge such withdrawals to my account.

Account Holder Name: ____________________________________________________________________________ Bank Name:_____________________________________________________________________________________ Bank Address:___________________________________________________________________________________ Bank Routing No.:_______________________ Checking Account No.: _____________________________________ The reverse side of this form must also be completed >

Please remember to notify us if:

· You move to another state, since it may affect your monthly premium. · The bank you use changes its name or merges with another bank. Please call your bank for the new account number. · You change banks. If someone else maintains the finances for your account, or you want to use your savings account for EFT withdrawals, please call a UnitedHealthcare Customer Care Associate at the phone number listed below for special instructions.

This diagram is for informational purposes only. Please do not send a deposit slip or cancelled check. Blank checks must be voided to set up EFT. Check Sample

John Doe 123 w. Main St. Anytown, USA 12345












Bank Routing Number

Bank Account Number

Please refer to the above diagram to obtain your bank routing information. If you have questions regarding EFT, please call UnitedHealthcare Customer Care at 1-888-867-5575, TTY users should call 1-877-730-4192, 24 hours a day, 7 days a week.

These Medicare Prescription Drug Plans (PDPs) are insured by United HealthCare Insurance Company or United HealthCare Insurance Company of New York for New York residents (together called "UnitedHealthcare"). AARP MedicareRx Plans carry the AARP name, and UnitedHealthcare pays a fee to AARP and its affiliate for use of the AARP trademark and other services. Amounts paid are used for general purposes of AARP and its members. AARP is not the insurer. AARP does not make prescription drug plan recommendations for individuals. You are strongly encouraged to evaluate your needs before choosing a prescription drug plan. UnitedHealthcare contracts with the Federal government as a PDP sponsor.

This authority remains in effect until United HealthCare Insurance Company (United HealthCare Insurance Company of New York for New York residents) and the named banking facility receives notification from me of its termination in such time and manner as to give United HealthCare Insurance Company and the banking facility a reasonable opportunity to act on it. I have the right to stop payment of a withdrawal by notification to the named banking facility in such time as to give the banking facility a reasonable opportunity to act upon it, with the understanding that such action may put my plan account in arrears. Member Name:__________________________________________________________________________________ Member Address: _______________________________________________________________________________ City:_______________________________________________State: __________________Zip: _________________ Member Phone Number: (______)________________________ Member ID Number: __________________________ Signature:_________________________________________________________ Date: _______/_______/_______ S5820S5805S5921S5917_PDP2378E_0001 EFPDP2378_XACE001



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