Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the BlueCross BlueShield Association serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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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