coupehealth

Primary Insured First Name

Primary Insured Last Name

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

Primary Insured Email

I agree to the eSign Disclosures (en español) and to receive electronic account records, have the required hardware and software to access and retain electronic records, and to sign all account documents electronically.

I agree

By signing below, you represent and agree that you have opened and viewed the Multiple Advance Loan Agreement (en español) and the Privacy Statement (en español) and agree to the terms and conditions of the agreements.

I agree

Thank you for signing the financial agreements! Next, add a payment account to your payment profile.

Paytient’s banking lendors require each plan member have an account on file to pay at least the minimum monthly financing payment on a monthly basis. Once you add an account, you can use it to set up an automatic payment plan to eliminate the worry of having to remember a monthly payment. Adding an account to your payment profile is necessary to enroll and be eligible for the health plan.

Bank Account Debit/Credit Card HSA/FSA

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.

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