PO Box 30192 DUE DATE TOTAL DUE SHOW AMOUNT
Salt Lake City, UT 84130-0192 PAID HERE
7/1/2021 $130.48 $
Group ID: I1000007
Subscriber ID: 802171429
02-01 004084
ALEXANDER RAMOS
211 WYMOUNT TER SELECTHEALTH
BLDG. 4C APT. 211 PO BOX 3674
PROVO, UT 84604-1937 SEATTLE, WA 98124-3674
054100080010000802171429000001304820
DETACH ABOVE AND RETURN WITH PAYMENT
PREMIUM BILLING STATEMENT
Group ID: I1000007 Invoice Number: 211680078600
Subscriber ID: 802171429 Invoice Date: 6/17/2021
Balance From Previous Statement: $86.40
Monthly Transactions
Monthly Plan Premium
7/1/2021 MEDICAL PREMIUM $44.08
TOTAL AMOUNT DUE $130.48
The statement you are currently receiving includes the advanced payment tax credit that you have qualified for through the federal Marketplace. The
amount owing is the member responsibility after the credit has been applied.
Premium payments are due on the first day of the month with a 90-day grace period. If payment is not received within the first 30 days of the grace
period, claims will begin to not be processed after that time until full payment is received. If your account is still outstanding at the end of the 90-day
grace period your policy will be terminated back to the end of the first 30 days of the grace period. Once a policy has been terminated for nonpayment
of premium, any claims that have been incurred will be your responsibility to pay and you may be without coverage until the next open enrollment
period. Also, you may owe a penalty when you file your federal income tax return for the year if you have gaps in qualifying coverage of three months
or more during the year.
If you have questions regarding this statement or wish to change how you pay your monthly premiums, call Billing at 844-442-4106.
Please be aware that if your policy is cancelled and you have any unpaid premium balances, this will affect any
future enrollment with us. All unpaid balances will need to be paid before you may enroll in the future.
© 2013 SelectHealth. All rights reserved. 2563 11/13
0202-004084
How to Pay Your Premium
PAYING YOUR PREMIUM STEP 1
IS EASY.
REGISTER (if necessary)
If you haven’t already created your
SelectHealth account, that’s your first
step. Go to selecthealth.org and click
the “Member Login” button at the top
of the page. Once you’re there, click
“Create Account” and follow the steps
to set up your account.
Now you’re ready to set up automatic or
one-time payments with Online Bill Pay.
Here’s how:
Step 1: Log in to your STEP 2 STEP 3
SelectHealth account.
Step 2: Click “Payments” to
access Online Bill Pay.
Step 3: Click “My Wallet” to add
your payment information. Payments
Click here to
access Online
Step 4: Select “Automatic Payments” Bill Pay
to set up auto pay, or My Wallet
Click here to
select “Pay Now” to make a add payment
information
one-time payment.
Note: Automatic payments will
be processed on the 1st of STEP 4
each month.
Run into a snag?
For answers to common payment questions, visit our FAQ page
at selecthealth.org/faq. If you’d like to talk with someone
directly or make a payment over the phone, please give us a call. Automatic
Payments
We’re available at 844-442-4106 weekdays, from 8:00 a.m. to Click here to
make recurring Pay Now
8:00 p.m., and Saturdays from 9:00 a.m. to 2:00 p.m. payments
Click here to
make a one-
time payment
© 2020 SelectHealth. All rights reserved. 1199329 11/20
