Aetna Electronic Funds Transfer Authorization Agreement

ERA is a safe and convenient alternative to paper reporting. Sign up electronically via CAQH. CAQH Registration Office This authorization remains in effect until Aetna is terminated by the member. The member will provide Aetna with thirty (30) days in advance in writing on the termination or modification of the deposit establishment or other payment instructions. Only one bank account is allowed per family. Before sending this authorization form, the member should ask the bank if it will be able to obtain transactions with the Automated Clearing House (ACH) and if a fee is charged for this service. The member accepts that Aetna is not responsible for these costs. If you think you are missing an EFT, please check your account over four days to see if the funds have been settled another day. If you still can`t find the missing EFT, please contact your bank.

If your bank is unable to resolve your application, please contact us. You can check claims electronically on our secure website. Electronic Transfer (EFT) /Direct Deposit Authorization Form FOREIGN SERVICE BENEFIT PLAN PO BOX 14079 Lexington, KY 40512-4079 FAX: (959)282-1516 If you would like to send this form by fax or mail, you can download the form here: www.afspa.org/filestoreAFSPA/AETNAEFTDirectDepositForm.pdf and send to: If you would like to continue receiving a copy of your EOB on paper, please check here, if you think you are missing an ERA file, wait four business days. If you still haven`t received it, please contact your ERA provider. If your creditor is unable to resolve your application, the supplier can conduct a more thorough investigation for you or order you to contact us. . The member of the Foreign Service Benefit Plan (“member”) authorizes Aetna Life Insurance Company and its associated companies (Aetna) to make electronic transfer payments (EFT), (2) certifies to the Member that he has chosen the next custodian and (3) indicates that all of these water assistance payments are made as shown below. If executed correctly, this authorization will take effect within 30 days of Aetna receiving it.

0