Payment Arrangement by check

Required fields are in red
Name and Address Information
First Name: M.I.  Last Name:
Address1: Address2:

State:      Zip:
Home Ph#: () - Work Ph #: () -
Account Information
Balance Owed To:
Account #:
Account # Type:

Checking Account Information
Check this box to copy information from the name and address information already entered.

First Name:
M.I.  Last Name:
Address1: Address2:

State:      Zip:
Please Complete if an Additional Name Appears on the Check.
First Name: M.I.  Last Name:
Bank Name: Bank Branch:

State:      Zip:
Routing #: Acct #:  
Payment Data
Method 1: Single payment of $ Check # ,
to be deposited on
Method 2: Multiple Payments: Please specify up to ten payments below:
Check # Amount Deposit Date

With submission of the Check payment request, I hereby authorize Med-Plan to debit my checking account in the amount(s) indicated above for the purpose of credit toward my outstanding balance.

After clicking the “Submit Information” button, you will see a printable receipt page. Please print and save for your records.

If you provide an e-mail address in the box below, you will receive a confirmation e-mail of this transaction.

My e-mail address is:

Please note, Med-Plan does not recommend using a work-related email address for this purpose.

The confirmation e-mail will arrive via a “” e-mail address. Please adjust your spam filter if necessary.

Thank you for utilizing