Authorization…

                                                  Authorization Agreement for
                                                  Blue Cross and Blue Shield of
                                                  New Mexico Automatic Pay
                                                  I (we) authorize Blue Cross and Blue Shield of
Automatic Pay                                     New Mexico (BCBSNM) to initiate deductions
                                                  from the checking account named below and
An Automated Payment Plan                         the named banking facility (BANK) to charge
for Your Convenience                              such deductions to my (our) account.

                                                  BANK NAME: _______________________________
What is Automatic Pay?
Automatic Pay allows your preauthorized           ACCT NUMBER: ____________________________
deductions from your personal checking
account to be deposited directly with             BANK ADDRESS: ______________________________
Blue Cross and Blue Shield of New Mexico
                                                  ____________________________________________________
(BCBSNM) for payment of your health care
coverage. This service is offered for your
                                                  ____________________________________________________
convenience.
                                                  This authority remains in effect until BCBSNM
Why Should I Use Automatic Pay?                   and BANK receive written notification from me
Automatic Pay offers several advantages to        (or either of us) of its termination in such time
BCBSNM customers.                                 and manner as to give BCBSNM and BANK a
                                                  reasonable opportunity to act on it or until such
· It saves the time and cost of writing checks.   time as my (our) health care contract is
· It saves postage expense.                       terminated by me (or either of us) or BCBSNM.
· It ensures timely payment of your health care   I (we) have the right to stop payment of a
  coverage, even when you are away on             deduction by notification to BANK in such time
  vacation or unable to personally ensure         as to give BANK a reasonable opportunity to
  payment by check.                               act upon it, with the understanding that such
· It gives you a record of your payment on your   action may put my (our) health care contract in
  bank statement.                                 arrears and subject to termination. I (we) have
                                                  the right to have any erroneous deduction
How Do I Apply for Automatic Pay?                 credited to my (our) account by notifying BANK
                                                  within 15 days following issuance of the
Complete the authorization agreement at right,    account statement.
and mail this form and a voided check to:
  Blue Cross and Blue Shield of New Mexico        NAME(S): ________________________________________
  Individual Product Administration
  PO Box 27630                                    ____________________________________________________
  Albuquerque, NM 87125-7630                      Only current Subscriber supplies following
For Automatic Pay to start on a given             number; new applicant leaves blank:
month, the following must happen                      SUBSCRIBER
by the 15th of the prior month:                       NUMBER: __________________________________
1. Application for coverage is approved.
2. If new member, 1st premium is paid by check    SIGNATURE(S):
   and received by BCBSNM.
3. Established members must be paid current.      x _________________________________________________
4. Automatic Pay Agreement is received by
   BCBSNM.                                        x _________________________________________________
What If I Change Bank Accounts?                   DATE: ____________________________________________
Notify BCBSNM immediately to obtain a new         IMPORTANT: Please attach a blank, voided
authorization form to ensure continuous           check for the banking account from which you
payments.                                         want your deductions taken.

M574 (Rev 05-03)                                                              f:\collateral\AutoPay\M574-AutoPay05-03.doc