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.

122315 

WW-0023C
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