Authorization Request by Phone for Electronic Check/ACH - Anthem 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section 1, enter your Group Information. Fill in the group name, group number, legal company name, street address, city, state, ZIP code, and contact details including phone number, fax number, and email address.
3. Proceed to Section 2 for Financial Institution Information. Input the financial institution's name and address. Include the transit routing number (9-digit ABA routing number) and account number. Select the type of bank account from the options provided: personal/consumer savings or checking, or business/commercial savings or checking.
4. Review the authorization statement carefully. Ensure you understand that this authorization begins upon receipt by Anthem and remains effective until a written notice is sent to terminate it.
5. Complete the signature section at the bottom of the form. Enter the date, printed name of the signer, and provide a signature to authorize.
6. If you wish to terminate this agreement later, fill out Section 3 with similar details as required for authorization.

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