Check It Out^® enrollment/change form

Required fields are noted with an asterisk *.

* Reason for submitting form

Enrolled Child's Information
* CHIP Member Full Name			* Identification Number (as it appears on the ID card)
* Parent or Guardian's Full Name			* Daytime Telephone Number

Address Information
* Street Address
* City	* State	* ZIP Code
* Is this a new address?

Financial Institution Information
* Account Type

* Name of Financial Institution	* ABA Number	* Confirm ABA Number
* Name on Bank Account	* Bank Account Number	* Confirm Bank Account Number
* Signature of CHIP Member Head of Household
Signature if joint account	Signature if account does not belong to a parent or guardian	Date

By completing this form, I/we authorize Capital BlueCross and its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^®, and Keystone Health Plan^® Central, and the financial institution named above, to deduct the amount of the premiums for my child's health coverage from my account.

I agree to maintain sufficient funds in the account to permit these deductions. If the account does not have sufficient funds at the time of transfer, I understand that my child's Capital BlueCross health care coverage may be cancelled.

By typing my full name below and submitting this form, I understand that I am creating an "Electronic Signature" that carries the same legal obligations of a written signature.

* Authorized Signature (acts as electronic signature)

* Date Submitted

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Check It Out^® enrollment/change form