Check It Out® Enrollment/Change Form

Required fields are noted with an asterisk *.

Enrolled Child's Information
Address Information
Financial Institution Information
The ABA/transit routing number is the first 9 numbers on the bottom left corner of your check. The account number is the 10 numbers on the bottom right corner of your check.

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 signatureName.

(acts as electronic signature)

Clicking 'submit' certifies the information provided is true and correct.