For Your Monthly Premium Payment 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by completing, signing, and dating the authorization section. This is crucial for initiating your automatic bank withdrawals.
3. Select one of the options to start, update, or stop your automatic bank withdrawal information.
4. Indicate the month you wish to implement the changes by filling in the MM/YY format.
5. Provide your policyholder information, including the type of insurance plan (Individual or Employer Group), your name or employer group name, and your policy/member number or Social Security Number.
6. Fill in your email address for communication purposes.
7. Choose between a checking account or savings account and provide the necessary banking details such as bank name, city, state, account holder's name, account number, and routing number.
8. Sign and date the authorization section to confirm your agreement for automatic withdrawals.
9. Finally, mail or fax the completed form along with a voided check or copy of a check to DAKOTACARE Finance Dept.

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