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This version of the form is not currently in use and is provided for reference only. Download this version of
Form HCA42-0450
for the current year.
Form HCA42-0450 Pebb Electronic Debit Service Agreement - Washington
What Is Form HCA42-0450?
This is a legal form that was released by the Washington State Health Care Authority - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form HCA42-0450?
A: Form HCA42-0450 is the PEBB Electronic Debit Service Agreement for Washington.
Q: What is the purpose of the form?
A: The purpose of the form is to authorize the electronic debit service for PEBB payments.
Q: Who needs to fill out this form?
A: This form needs to be filled out by PEBB enrollees who want to authorize electronic debit for their payments.
Q: Is there a fee associated with using the electronic debit service?
A: No, there is no fee for using the electronic debit service.
Form Details:
- Released on July 1, 2022;
- The latest edition provided by the Washington State Health Care Authority;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form HCA42-0450 by clicking the link below or browse more documents and templates provided by the Washington State Health Care Authority.
Download Form HCA42-0450 Pebb Electronic Debit Service Agreement - Washington
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