Primary Billing Number and Member Number Please have both numbers available when calling customer care.
Due Date
Your bill must be paid in full on or before this date to avoid possible late fees.
Payment Account/Credit Card/Bank Deduct
Please indicate the payment amount included with your remittance. If Credit Card or Bank Deduct, your payment will be made automatically on the 20th of each month and there is no need to send a payment.
Change of Address/Payment Options
Check this box and complete form on reverse to change your mailing address or set up automatic payments.
Previous Balance
Balance from the previous month(s) bill.
Payments
Total of all payments applied during previous month.
Balance Forward/Past Due Balance This amount, if any, is due immediately on your account.
Total Current Charges Total of this month's current activity
Total Amount Due Current Charges plus Past Due Balance. You will need to pay this amount.
