Kaiser Permanente Authorization for Online Bill Payment

Authorization for Payment of First Month’s Premium

The following authorization is for the payment of my first month’s premium for Kaiser Permanente coverage. I certify that I am an authorized user of the credit card/bank account information I am providing.

Payment by Credit Card (Visa, Mastercard, American Express or Discover):

I authorize Kaiser Foundation Health Plan, Inc. to charge (and/or apply credits, if correcting errors to previous charges) the credit card provided by me and for the amount owed for my first month of coverage as that information appears in the Payment Due Now section of my monthly premium statement.

I understand that if my application for coverage is approved, my credit card will be charged at that time for my first payment. If the payment date falls on a weekend or holiday, I understand that my payment will be processed as of the next business day. There will be no service fee for this transaction. Authorization for payment by credit card does not constitute approval of my application for coverage.

Payment by Checking or Savings Account (includes ATM or debit card)

I authorize Kaiser Foundation Health Plan, Inc. to initiate a debit to the bank account/ATM/ debit card provided by me and for the amount owed for my first month of coverage as that information appears in the Payment Due Now section of my monthly premium statement. I also authorize my financial institution to reduce the balance of my account by the amount of such debits (and/or corrections to previous debits). I will maintain sufficient funds in my account for the full amount of the payment owed, and understand that if the automatic debit transaction fails (e.g., no funds are available), I will be responsible for, and Kaiser Foundation Health Plan, Inc. may collect a returned item service fee (minimum $25) from my account.

I understand that if my application for coverage is approved, my account will be debited at that time (or within 1 to 2 business days of that approval date). There will be no service fee for this transaction. Authorization for payment using my bank account/ATM/debit card does not constitute approval of my application for coverage.

Please print a copy of this authorization form and keep it with your records.

Authorization for Recurring Payment of Premium

The following authorization is for the recurring payment of my monthly premium for Kaiser Permanente coverage. I certify that I am an authorized user of the credit card/bank account information I am providing. I understand that I will not pay service fees for these recurring payments except as specifically provided herein.

Payment by Credit Card (Visa, Mastercard, American Express or Discover):

I authorize Kaiser Foundation Health Plan, Inc. to charge (and/or apply credits, if correcting errors to previous charges) the credit card provided by me and for the (1) amount owed for my coverage each month as that information appears in the Payment Due Now section of my monthly premium statement or (2) lesser amount that I owe. I understand and agree that my payments may vary from month to month depending on whether I owe an amount that is less than the Total Balance Due as shown on my monthly premium statement, and I understand and agree that this lesser amount will never be more than that Total Balance Due. The lesser amount will reflect payments made by me and/or credits to my account that are posted to my account at least 48 hours before my credit card is charged. I understand and agree that the monthly premium statement will be the only notice of the maximum charge to my credit card. I understand my credit card will be charged as of the monthly payment date that I have selected (or within 1 to 2 business days before or after that date).

Payment by Checking or Savings Account (includes ATM or debit card)

I authorize Kaiser Foundation Health Plan, Inc. to initiate debits (and/or make corrections to previous debits, as necessary) to the bank account/ATM/debit card provided by me (the “Payment Account”) and for the (1) amount owed for my coverage each month as that information appears in the Payment Due Now section of my monthly premium statement or (2) lesser amount that I owe. I understand and agree that my payments may vary from month to month depending on whether I owe an amount that is less than the Total Balance Due as shown on my monthly premium statement, and I understand and agree that this lesser amount will never be more than that Total Balance Due. The lesser amount will reflect payments made by me and/or credits to my account that are posted at least 48 hours before my Payment Account is debited. I understand and agree that the monthly premium statement will be the only notice of the maximum debit to my Payment Account. I also authorize my financial institution to reduce the balance of my Payment Account by the amount of such debit (and/or corrections to previous debits). I understand my Payment Account will be debited as of the monthly payment date that I have selected (or within 1 to 2 business days before or after that date). I will maintain sufficient funds in my Payment Account for the full amount of the payment owed, and understand that if the automatic debit transaction fails (e.g., no funds are available), I will be responsible for, and Kaiser Foundation Health Plan, Inc. may collect, a returned item service fee (minimum $25) from me or my Payment Account

Notice to Change or Cancel is Required 

I will continue to be charged/debited the amount of premium owed until I cancel this recurring payment upon at least 10 calendar days’ notice before a charge/debit is to occur. To cancel this recurring payment authorization, or if there are changes to my credit card or Payment Account, I must contact Kaiser Permanente Member Services at the number on my member ID card or on my premium bill statement. Kaiser Foundation Health Plan, Inc. may cancel this
authorization at any time upon notice to me.

Through my signature to this authorization, I agree to the terms and conditions described on this authorization form and I acknowledge I have been provided a copy of this form. I understand that this authorization and its contents shall control as to the subject matter hereof except when prohibited by applicable law. I acknowledge that all payment transactions must comply with applicable provisions of federal and state law.

Please print a copy of this authorization form and keep it with your records.

Notice to California Residents

Rosenthal Fair Debt Collection Practices Act

In the event your account has been assigned to a collection agency, state and federal law requires debt collectors to treat you fairly and prohibits debt collectors from making false statement or threats of violence, using obscene or profane language, and making improper communications with third parties, including your employer. Except under unusual circumstances, debt collectors may not contact you before 8 a.m. or after 9 p.m. In general, a debt collector may not give information about your debt to another person, other than your
attorney or spouse. A debt collector may contact another person to confirm your location or to enforce a judgment. For more information about debt collection activities, you may contact the Federal Trade Commission by telephone at 1‐877‐FTC‐HELP (382‐4357) or on‐line at www.ftc.gov. Nonprofit credit counseling services may be available in your area.

Notice to Colorado Residents

Colorado Revised Statutes Section 6‐20‐202

Pursuant to Colorado Revised Statutes Section 6‐20‐202(1)(b), we are required to inform you of the last date on which we will accept your payment prior to sending your account to a collection agency or reporting adverse information concerning your account to a credit reporting agency. Due to the requirements of this statutory section, we reserve the right to forward your account to a collection agency or report adverse information concerning your account to a credit reporting agency at any time after (30) days after the date of this notice
unless you have paid your account prior to such date.

Please print a copy of these terms and conditions and keep them with your records.

If you have questions about your payment, contact Member Services number on your member ID card.