Health care authority electronic debit service agreement form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by indicating if this is a new EDS account or a bank account change by selecting 'Yes' or 'No'.
3. Fill in the Subscriber’s Information section, including your name and social security number. If applicable, provide the social security number of a deceased PEBB retiree.
4. In the Bank Account Information section, enter the account holder’s name (if different), financial institution name, branch address, city, state, ZIP code, bank routing number, and account number. Select whether it is a checking or savings account.
5. Review the authorization statement carefully. Ensure you understand that withdrawals will occur on the 15th of each month and sign where indicated.
6. Finally, enclose a voided check or deposit slip and send the completed form to the specified address for processing.

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