coupehealth

Auto-payment program Account Selection Form

To protect the integrity of your account and meet the requirements for no credit-check, interest-free financing, Coupe Health requires that you participate in an automatic auto-payment program to pay your minimum due amount reported on your Coupe monthly statement. The auto-payment program only turns on if you miss making a minimum monthly payment by the statement due date.

Please complete the following fields with the primary plan member’s information, and click Next. You will then be prompted underneath to select your desired payment method for the Coupe Health auto-payment program.

Primary Insured First Name

Primary Insured Last Name

Primary Insured Date of Birth Date format - MM/DD/YYYY

Primary Insured Email

Primary Insured Last 4 of SSN

Bank Account Debit/Credit Card

By selecting the "Bank Account" option, you agree:

That this payment method may be automatically charged any minimum cost-sharing amounts that you fail to timely pay, and
That your health plan and Coupe Health and its vendors are not liable for any additional fees charged to you by your banking institution, such as interest or overdraft fees.

Please note any unresolved failure to pay the minimum cost-sharing amounts due may result in Coupe Health forwarding your account to collections.

By selecting the "Credit/Debit Card" option, you agree:

That this payment method may be automatically charged any minimum cost-sharing amounts that you fail to timely pay, and
That your health plan and Coupe Health and its vendors are not liable for any additional fees charged to you by your banking institution, such as interest or overdraft fees.

If you are making this selection while already in the auto-payment program utilizing payroll deduction, you may still have payroll deductions taken for a period of time. Coupe Health is unable to stop any payroll deductions that have already been reported to your employer or employer’s payroll administrator for processing.

Failure to complete this form with accurate information and provide a form of payment will result in your payroll deduction authorization remaining in effect. Please note any unresolved failure to pay the minimum cost-sharing amounts due may result in Coupe Health forwarding your account to collections.

Please choose your preferred payment amount and timing:

AUTO-PAY MINIMUM DUE
WITH ACCOUNT ON FILE AUTO-PAY FULL BALANCE
WITH ACCOUNT ON FILE PAY ON YOUR OWN SCHEDULE
WITH YOUR PREFERRED METHOD*

*Payments are due at the end of each month. If we do not receive at least your minimum payment by the due date, we will charge your preferred payment account on file for the minimum payment due on the day following the due date. If you choose an auto-pay option, we will automatically charge your account, and you will not need to worry about managing due dates.

Loading