Electronic Payment Option Form

Electronic Payment Option Form

You can choose to have your monthly premium payment deducted automatically from your checking or savings account through the Electronic Payment Option Plan. Instructions for enrolling in this payment plan are included on the form.  Please note: The Electronic Payment Option is only available to members purchasing health and/or dental coverage directly with BCBSRI.  If you enrolled through HealthSource RI, please call 1-855-651-7873 for information about payment options.