Payment Arrangement by check
Required fields are in red
Name and Address Information
First Name:
M.I.
Last Name:
Address1:
Address2:
City:
State:
Please Select One
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
COLORADO
CONNECTICUT
DC
DELAWARE
FLORIDA
GEORGIA
GUAM
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
OTHER
     Zip:
Home Ph#:
(
)
-
Work Ph #:
(
)
-
Account Information
Balance Owed To:
 
Account #:
 
Account # Type:
Med-Plan Account # (found on our statements)
Provider Account #
Last 4 Digits of your Social Security Number
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:
City:
State:
Please Select One
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
COLORADO
CONNECTICUT
DC
DELAWARE
FLORIDA
GEORGIA
GUAM
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
OTHER
     Zip:
Please Complete if an Additional Name Appears on the Check.
First Name:
M.I.
  
Last Name:
Bank Name:
Bank Branch:
City:
State:
Please Select One
ALASKA
ALABAMA
ARKANSAS
ARIZONA
CALIFORNIA
COLORADO
CONNECTICUT
DC
DELAWARE
FLORIDA
GEORGIA
GUAM
HAWAII
IOWA
IDAHO
ILLINOIS
INDIANA
KANSAS
KENTUCKY
LOUISIANA
MASSACHUSETTS
MARYLAND
MAINE
MICHIGAN
MINNESOTA
MISSOURI
MISSISSIPPI
MONTANA
NORTH CAROLINA
NORTH DAKOTA
NEBRASKA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEVADA
NEW YORK
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VIRGINIA
VERMONT
WASHINGTON
WISCONSIN
WEST VIRGINIA
WYOMING
OTHER
     Zip:
Routing #:
Acct #:
  
Payment Data
Method 1:
Single payment of $
Check #
,
to be deposited on
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Method 2:
Multiple Payments: Please specify up to ten payments below:
Check #
Amount
Deposit Date
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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.
Comments
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 “MedPlanWebReceipt.com” e-mail address. Please adjust your spam filter if necessary.
Thank you for utilizing MedPlanPayments.com.