GROUP AUTOMATIC PAYMENT AUTHORIZATION

Group Name:*
Effective Date:*
Select One:*
Bank Name:*
Routing Number:*
Account Number:*
Account Type:*
Please Include a voided check with your completed authorization form
Credit Card Number:*
Expiration Date (mm/yy):*
CVV2*:*

*American Express cards: four-digit number on the front of the card. All other cards: three-digit number on the back of the card.
Consent*
*
I authorize Opticare Vision Services to deduct monthly premiums from the payment listed above. The automated payments will begin on the effective date shown above. I understand that the group will continue to receive monthly invoices, reflecting any applicable balances due, and that the invoices will serve confirmation of the amount to be charged to the payment account listed above.
Authorized Signature:*
Print Name:*
Email Address:*
Date:*

83755

Out of Network Reimbursement Request