General Forms

Automatic Withdrawal Form: Use this form to authorize premium payments through bank draft or a credit card.

Authorization for the Use and Disclosure of Information: Use this form to grant covered entity permission to release information to designated individuals.

Affidavit to Authorize Medico Insurance Company to Pay Policy Benefits: Use this form to authorize Medico Insurance Company to make payments of benefits under an insurance policy.

122817

WW-0023C
To Find Which of the Following Products Are Available in Your Area: