United Health Care OTC Catalog

By ecrowe | General Articles | 0 comment | 21 February, 2019 | 0

United Health Care OTC Catalog

This post will give members of the United Health Care HMO MAPD plans 1,2 and 3 access to the 2019 United Health Care OTC Catalog.

If you are a member of either a United Health Care Medicare HMO Plan 1, 2, or 3, you have an over the counter benefit as part of your health plan. Although each plan has different quarterly benefit amounts, you can use the same form to look up products and find out what is available to you. Please refer to your specific plan benefits to find out exactly what your OTC benefit amount is. You need to be aware that the quarterly over the counter benefit not transferable and cannot be used once a given quarter has ended. This means if you do not use your benefit for each quarter you simply lose it.

In fact, when you chose to use your over the counter (OTC) benefit you must do so in one single order. This means you should plan what you will need by looking through the United Health Care OTC catalog before the end of each quarter and order everything you think you will need at once. United Health Care will only allow you to place 1 order per quarter.

If you would like to view a copy of the United Health Care OTC Catalog, CLICK HERE FOR THE 2019 OTC for HMO MEDICARE ADVANTAGE PLANS 1 2 & 3.

You may order only items listed in the catalog for your OTC benefit.

The name of the company that handles the OTC orders is Firstline Medical. There are 2 ways to order. Either you can order by mail or you can order online. If you would like to order by mail you need to contact FirstLine Medical at 1-877-795-4521. You can call them from 7a.m. until 7 p.m. Monday -Friday and 7 a.m. until 4 p.m. Saturday (Central time). You will need to have your UHC card available before you call.

If you would like to place an order on line you can go to www.OTC-Essentials.com.

1. Click on REGISTER to create your account (you only need to register one time).
2. Login to check your balance, view product images and descriptions. Place your order.
3. Track your order status or manage your account information.

Please use these helpful tips to register on the website:
1. Have your health plan member ID card available.
2. When you enter your member ID, only enter the numbers that are before the dash.
3. Your Username is from 6 to 25 characters long.
4. Your Password is from 8 to 25 characters long and will need to have at least one number, one capital letter and one lower case letter. The password is case sensitive.

Additionally, if you need help finding the right Medicare plan or have questions on your current health care plan. Please contact us at 203-796-5403. Our agents will be happy to make sure you have the coverage you need at the best price for your budget.

Medicare Travel Benefits

By ecrowe | General Articles | 0 comment | 3 February, 2019 | 0

Medicare Travel Benefits

This post will give you some information about Medicare Travel Benefits. You should understand what medical coverage you have while you are away from home. In most cases, Medicare does not cover either health care services or supplies when you travel outside of the United States. Some exceptions to this rule are listed below.

In some instances, Medicare Part B may pay for services you get if you are on board a ship within the territorial waters that join land areas of the U.S.

Rarely, Medicare might pay inpatient hospital, doctor, ambulance services, or dialysis when the following happens

If you are in the U.S. and a medical emergency occurs and the closest hospital that can treat your condition is a foreign hospital.

While you are traveling through Canada an emergency occurs that needs treatment without unreasonable delay. If the Canadian hospital is closer than the nearest U.S. hospital that can treat you.

When you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your condition. This is the case, if there is an emergency or not.

In some instances, Medicare may cover medically necessary health care services you get on board a ship. This is the case if you are within the territorial waters that join land areas of the U.S. Although, Medicare will not pay for health care services you receive on a ship that is more than 6 hours away from a U.S. port.

Please note: If you are admitted to the hospital under the circumstances listed above; foreign hospitals are not required to file Medicare claims for you. You are responsible to submit an itemized bill directly to Medicare for all the services you receive.

If you do not fit into one of the situations described above:

You will have to pay 100% of the costs, in most cases. If you do fit into one of the situations above, you do not get the 80% coverage provided by Original Medicare.

For services that are covered, Medicare pays only for services that are covered under Original Medicare.

Medicare Part A

Part A covers the care you get when you are formally admitted as an inpatient by a doctor’s order to a foreign hospital.

Medicare Part B

Part B covers both emergency and non-emergency ambulance and doctor services you receive for your covered foreign inpatient hospital stay. You will be responsible for your portion of the charge for covered services. Your portion includes coinsurance & co-payments as well as deductibles, the same way it would if you received care in the U.S. You may want to ask your doctor for prices for tests, supplies and services. This way you will know how much you will owe your provider. There are various things that may decide your costs. This includes whether or not you have other insurance, how much the doctor charges, the type of facility, as well as where you get your tests, items or services.

Medicare does not pay for services such as return ambulance trips home when:

Medicare refused to cover your hospital stay.
You used either ambulance or doctor services outside the hospital after your covered hospital stay ended.

Medicare Travel Benefits, Please note:

The 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa are all considered part of the U.S.

Medicare drug plans don’t cover prescription drugs you buy outside the U.S.

Some Medicare supplement insurance (Medigap) policies cover you when you travel outside the U.S.

Medicare Supplement/Medigap coverage when you are outside the U.S.

Medicare Supplement Plans C, D, E, F, G, H, I, J, M or N: Plans C,F,G,M and N can actively be purchased.

Do Cover foreign travel emergency care that begins during the first 60 days of your trip, if Medicare does not cover the care.
Once you have met the $250 deductible for the year, Medicare supplements pay 80% of the billed charges for certain medically necessary emergency care outside the U.S..

There is a lifetime limit of $50,000 for foreign travel emergency coverage with Medigap policies.

If you would like more information on Medicare supplement plans, CLICK HERE

Be aware of your Medicare Travel Benefits before you go.

Before you take that trip outside the U.S., It is best to talk to either the customer service department of your insurance plan carrier or your insurance agent to get more information about your coverage before you travel.

Sometimes Travel insurance will help make up for limited Medicare coverage for health care services outside the U.S.

You can get information about travel insurance through your insurance agent or travel agent. Travel insurance doesn’t necessarily include health insurance, so it’s important to read the conditions or restrictions carefully.

Combining a HealthShare and Minimum Essential Coverage Plan

Combining a HealthShare and MEC Plan

By ecrowe | General Articles | 0 comment | 3 February, 2019 | 0

Combining a HealthShare and MEC Plan

Combining a HealthShare and MEC Plan provides coverage for health expenses at a reasonable cost. You will see below how the components of the plans and strategy work together. (Available in all 50 states!)

Example: The monthly premium for a 58 year old female is $290 for a MEC plan. The plan covers all preventative services, has co-pays for doctors visits and urgent care as well as ER with no deductible. She can cover the major medical services with an Altrua Health Share plan for $100 per month. However, this plan has a $7,500 cost share. After you have paid the $7,500, you will be covered in full up to $150,000 for the year. This policy has a $1,000,000 lifetime max!

MEC Copay plan

MEC enrollment portal CLICK FOR ENROLLMENT SITE

The MEC copay plan provides the following coverage: They do not check health for pre-existing conditions

ACA mandated preventative services are covered in full
$25 copay for primary doctor visits
$35 copay for specialist doctor visits (5 visits per person per year)
$50 for urgent care (limited to 3 visits per person per year)
$250 emergency room visit (limited to 1 visit per person per year)
Rx-Generic discount program
Network is First Health

Monthly premium for Minimum Essential Coverage Plans:

Age 18-44 = $170 month, age 44-59 = $190 month, age 60+ = $205 month
Spouse = $150, Spouse = $160 Spouse $180
Children $105

Healthshare for catastrophic coverage CLICK HERE FOR THE ALTRUA HEALTHSHARE ENROLLMENT SITE

You can use The Healthshare plan to cover yourself against major medical services such as hospitalization, outpatient surgeries or any other major medical expense (subject to pre-existing conditions clause)

Member pays the first 7,500 of costs and then is covered at 100% up to $150,000 per year for medical services
Life time max is $1,000,000
Network is PHCS Multiplan

Monthly cost for Healthshare plan:

$100 per month regardless of age
$50 per month for every additional dependent

If you Combine the two plans, they will provide an alternative to traditional healthcare at a price people might just be able to afford. Call our office at 203-796-5403 to inquire.

Medicare Easy Pay

By ecrowe | Medicare A and B benefits | 0 comment | 11 January, 2019 | 0

Medicare Easy Pay (Automatic deductions for Medicare Part B premiums)

Medicare Easy Pay is an electronic Medicare part B payment option for people to have their Medicare Part B premiums set up to draft from either a savings or checking account each month.

Can I sign up for Medicare Easy Pay?

Anyone who gets a bill for their monthly Medicare Part B premium is eligible for Medicare Easy pay. Those already drawing Social Security payments are paying out of their checks automatically and do not need to set up easy pay.

Note: Those with billing through Railroad Retirement Board (RRB), are not able to utilize the service.

How do I set up Medicare Easy Pay?

To get the Medicare Easy Pay form: just search Medicare payment forms

Mail the completed form to:

Medicare Premium Collection Center
PO Box 979098
St. Louis, MO 63197-9000

What happens once I sign up for Medicare Easy Pay?

Sometimes it takes 6-8 weeks for Medicare to process your application. If medicare cannot process your MEP application, they will return it to you with a letter of explanation.

Two things will happen each month after your request is processed:

You will get a Medicare premium bill stating “This is not a bill”. This will let you know that the premium will be deducted from your bank account.
Your premium will be deducted from your bank account. This usually happens on the 20th of the month. The deduction will appear on your bank statement as an “Automated Clearing House (ACH)” transaction.

Medicare will try to deduct your premium only one time per month. If there is a problem processing your premium deduction, you will receive a letter with instructions on how to make a direct payment to Medicare.

Do I need to do anything when my premium amount changes?

No, Medicare will deduct the new premium amount from your bank account auomatically.

What if I want to change bank accounts or stop Medicare Easy Pay?

You would complete another payment authorization form(SF-5510), and indicate the type of change you want to make. Mail the completed form to the address above.

If you would like more information about Medicare; contact us either by phone at (203)796-5403 or email at [email protected]

Signing up for Medicare A and B

By ecrowe | General Articles | 0 comment | 11 January, 2019 | 0

Signing up for Medicare A and B

We want to give you some help when you are Signing up for Medicare A and B. This can be a stressful time for some people with all the mail and calls they receive.

Medicare A and B will begin the first of the month someone turns 65 years old.
If you receive social security payments for at least 4 months before the month you turn 65, you will get Medicare A and B automatically. Those not receiving payments will need to sign up for A and B online or at the local social security office.
- If you have not been receiving Social Security payments for the 4 months before you turn 65, you will need to sign up for both A and B. You will not get it automatically.
- Here is the link for those that need to sign up CLICK HERE TO SIGN UP FOR MEDICARE ONLINE The online enrollment is simple and only takes about 15 to 20 minutes
- Please Note: If you are past the age of 65 and want to sign up for Medicare part B, it cannot be done online. You must go to the local social security office to sign up. We suggest that you call the office first to make an appointment.
Signing up for Medicare A and B – Medicare billing for part B
- If you are already receiving Social Security payments, the part B premium will be deducted from your SS payments.
- If you currently do not not receive Social Security payments, you will be billed quarterly for part B. Medicare will allow you to pay the premium automatically if you fill out a form to set it up.

Signing up for Medicare A and B – Who should enroll in Medicare Part B

If someone is working and receiving health benefits through work or if they receive health benefits through a working spouse, they do not need to sign up for part B of Medicare. (Assuming they will continue to get work benefits)
If either they or the spouse they get benefits through stops actively working, they need to sign up for Medicare Part B. Note: Those with groups of less than 20 employees may need to sign up for part B when they turn 65 regardless of work status.
- Retiring is a special election for Medicare Part B. You will need to take a completed Employment verification form to the Social Security office to sign up for B. The effective date will be the first of the month after you retire.
- If you are still actively working but no longer receive coverage, that is also considered a special election to sign up for Medicare Part B.
- You have an 8 month window to sign up for Part B. The 8 months start from the date you either retire or lose coverage
- If you fail to sign up for part B under either of the scenarios above, it will result in a Part B penalty The penalty is 10% of part B premium for every 12 months you did not have part B. If you delayed part B enrollment and missed your special election period, you should sign up during the Medicare Part B general enrollment period. The general enrollment is from Jan 1 through March 31 to sign up for a July 1 start date. Those that miss the general enrollment will need to wait for the next general enrollment to sign up unless they qualify for a special election period,
click here for employment verification form.

Signing up for Medicare A and B – Employer groups with less than 20 employees

According to Medicare, someone employed by a group with less than 20 employees needs to sign up for both Medicare A and B at age 65. This is true even if you have health coverage from work and are still working. In reality, I have had a number of people who work in groups less than 20 delay part B. Those people have not paid a penalty when they enrolled in B later down the road. They also did not have any issue with the special election to enroll in B. Regardless, the Medicare rule says they should enroll when turning 65. It is up to you how you choose to proceed in this situation.

Signing up for Medicare A and B – Contributions for those on Medicare A and B

Those with Medicare A and/or B are advised not to contribute to an HSA account. If you are selected for an audit, you may be receive a penalty. This means your contributions are included in your taxable income. You will also pay a 10% penalty on the contribution.

Aetna Medicare Over The Counter Catalog 2019

By ecrowe | General Articles, Medicare, Medicare Advantage Plans | 12 comments | 24 October, 2018 | 0

OTC Catalog

The Aetna Medicare Over The Counter (OTC) Catalog 2019 is now available.

Carriers now offer a Medicare over the counter (OTC) benefit to their members. In addition to your plan benefits, over the counter benefits defray some of the cost of necessary healthcare items not covered as a medical or pharmaceutical expense.

Aetna Medicare offers members an Over-The-Counter benefit. This benefit pays up to a $25 maximum amount every month for over the counter (OTC) items. The catalog lists eligible items. Only items listed in the OTC catalog are covered by the over the counter benefit. Many products you would normally purchase from a drugstore are critical to a healthy lifestyle. These items may include non-prescription medications, vitamins, and eye care. In addition to these you can purchase every day items that impact your health, like hand sanitizer. This benefit allows you to purchase these items from the catalog at no cost to you. Accordingly, the cost of these items is part of your Medicare OTC benefit.

The over the counter benefit in 2019 is up to $25/member every month. However, there are rules with regard to how items must be ordered.
The over the counter benefit is included with all Aetna Medicare Advantage plans in 2019.
You must order from the catalog or online. Items purchased from a retail store are not part of the benefit.
Because this is a “use it or lose it” benefit, benefit dollars do not carry over month to month. Therefore, be sure to check the catalog each months for items you will need.
You cannot use your CVS Extra Care card toward these purchases.
Free shipping! There are no shipping or handling fees.
Orders typically take two weeks to arrive. Plan ahead for adequate supplies.

Please see below to download the color format OTC catalog. The catalog includes a newly expanded product list.

CLICK HERE TO DOWNLOAD THE AETNA MEDICARE 2019 OVER THE COUNTER CATALOG.

You can place an Over the Counter order 2 ways. You can order either by phone at 1-888-628-2770 Monday through Friday 9:00am to 8:00pm EST, or you can order online at visit:myorder.otchs.com.

Choosing a Medicare plan can be confusing! Remember, that is what we specialize in! If you still need help determining which Medicare option will suit you best, call us at 203-796-5403 and schedule an appointment today.

Agents can click for a Medicare Scope of Appointment

Your new Medicare card, Things to know

By ecrowe | General Articles | 0 comment | 17 September, 2018 | 0

Your new Medicare card, Things to know

Social Security is still busy sending out the new medicare cards in the mail. You can click this link to get an email when your new card has been put in the mail new Medicare cards. This will give you an idea when to expect receipt of the new card. This way you can keep an eye on the mail for it. Many of the new cards have already been sent out. If you have not yet received your new card, do not worry. It will get to you in the very near future.

If you need to get your new Medicare card ID, you can click the following link to create a free Medicare account. From there you will be able to get your new Medicare number without having to wait for it to arrive in the mail. CLICK THIS LINK TO CREATE A FREE MEDICARE ACCOUNT.

Once your new card arrives in the mail, you can use it right away. There are a few things you need to do once your new card arrives:

Always Carry your new Medicare card with you.

Keep in mind that your doctors and health care providers are aware that you will be receiving it and they will want to see your new Medicare ID when you come into their office for care.

Destroy your old Medicare card. You no longer need the old card for anything, so the best thing to do with it is to carefully and completely destroy it. You do not want anyone getting your information.
Keep your Medicare Advantage Plan card. If you are currently enrolled in a Medicare Advantage Plan, (an HMO or PPO), you will continue to use your Medicare Advantage Plan ID card when you use a health care provider. Please keep in mind you will also need to carry your new Medicare card, because you health care providers will ask to see it. Remember, these new cards are safe to carry with because they do not use you social security number anymore.
If you have a Medicare Drug plan card you will also need to keep that with you.

Do not worry that your new Medicare card looks different than the old one. Your Medicare coverage and benefits have not changed. If you would like more information about the new Medicare card you can click here.

If you need help with choosing Medicare plans, please contact our office. You can reach us either by phone at (203)796-5403 or by email at [email protected]

to learn more about us; visit croweandassociates.com.

How Much is Medicare part B

By ecrowe | General Articles | 0 comment | 17 September, 2018 | 0

How Much is Medicare part B

When you are getting close to the age of 65, you might get a little anxious thinking about what steps you need to take to get you Medicare benefits. One of the questions you probably have is How Much is Medicare part B. . If you are retired and living on a fixed income this is an important question to ask. Medicare Part B covers your necessary medical services and supplies. In 2018 the standard cost for Medicare Part B is $134.00 a month for an individual.

According to federal law, some higher-income beneficiaries will have to pay a higher premium for their part B coverage. This law also applies to your Medicare prescription drug coverage. Less than 5% of people will be affected by this law. Therefore, the majority of people will not have to pay the additional premium.

The document in the link below is for 2018; but the IRMAA limits are set to be the same for 2019. They will most likely go up substantially in 2020.

CLICK HERE FOR MORE INFORMATION AND INCOME/PAYMENT AMOUNTS

How Much is Medicare part B – Social Security will use your most recent tax return

Your most recent tax return will be used to decide if you need to pay the higher premium. The amount is based on your (MAGI) modified adjusted gross income. Your MAGI is your total adjusted gross income along with your tax-exempt interest income. If you are filing as single and your MAGI is more than $85,000,you will pay a higher Part B premium. In the event that you are married, filing jointly and your MAGI is greater than $170,000 you will pay a higher Part B premium. If you will have to pay a higher premium, you will receive a letter from Social Security with the reason for the higher cost as well as the amount you will have to pay.

When you have income that is not over the set income limits you will not have to pay any additional premium.

If your income has gone down, due to a change in your life, you can contact Social Security and explain it to them. They will need proof/documentation of the new information and may adjust your payment amount accordingly. We list some examples of life changes below:

You or your spouse stops working or has reduced hours.

An unforeseen event causes you to lose an income-producing property.

Recently you were either married, divorced or widowed.

You have lost income from a pension plan.

In the event that your income has gone down, you can use Form SSA-44 to ask for an adjustment. You can find the form on line at www.socialsecurity.gov/forms/ssa-44.pdf.w.

If you would like more information or help with signing up for Medicare, please contact the office. You can reach us either by phone at (203)796-5403 or by email at [email protected]

New Medicare Card Scams

By ecrowe | General Articles | 0 comment | 14 August, 2018 | 0

New Medicare Card Scams

Unfortunately, there have been reports of some New Medicare Card Scams.

Please note: Medicare will never call you without your permission. They definitely will not call to ask for personal or private information to get your new Medicare Number, Medicare card or anything else. Scammers are always looking for new ways to get your personal information. They may call and ask for your current Medicare Number and use the excuse that is is about your new card. This is not Medicare or anyone associated with Medicare.

In the case that anyone asks you either for personal information, money, or threatens to cancel your health benefits, this is a scam. DO NOT share your information, hang up and call Medicare at 1-800-MEDICARE (1-800-633-4227).

Be aware that Medicare is in the process of sending out the new Medicare cards.

Therefore, if you receive a call and someone says you need to give them your personal information or payment of any sort to get the new card, hang up! It’s a scam. Medicare will never call uninvited and ask for personal information or money the cards are free and Medciare already has all the information they need to get the card to you. Click this link to check the status of your new card.

If you have not received your new Medicare card yet, don’t worry. Sending cards out to each state takes some time. You and your friends will probably get your cards at different times. If you do not have your new card yet, you can keep using your current Medicare card.

Additionally, you are able to log in to your MyMedicare.gov account to see when your new card was mailed. To sign up for a free Medicare account you can go to MyMedicare.gov and in a short amount of time you can create an account.

IMPORTANT: If you have received your new card, start using it right away!

The new card will have a new Medicare Number that’s unique to you, instead of your Social Security Number. This change is in place to protect your identity.

YOUR NEW CARD WILL LOOK LIKE THIS:

New Medicare Card

PLEASE REMEMBER:

Your new card will automatically be mailed to you. There is nothing for you to do. Just wait for the card to arrive, as long as your address is up to date. If you need to update your address, visit your My Social Security account.
Once you get your new Medicare card, you should destroy your old Medicare card and start using your new card.
Medicare uses a unique combination of numbers and letters on the new cards. They use numbers 0 thru 9. They do not use the letters S, L, O, I, B, or Z on the cards.

Call Crowe and Associates with any questions at 203-796-5403

Medicare Employment Verification form

By ecrowe | General Articles | 0 comment | 26 July, 2018 | 0

Medicare Employment Verification form

You might wonder why you would need a Medicare employment Verification form? If you are going to apply for Medicare in a special enrollment period you need to have had group plan coverage within the last 8 months through either yours or your spouse’s employer.

If you have a disability you must also have had large group health plan coverage through either your own or your spouse’s employment. The Medicare verification form is used to prove that you have had or have this coverage. It is needed to process your Medicare enrollment application. The employer that provides you with health coverage will complete some sections of this form for you. The form includes information about your health care coverage as well as the dates of employment.

Click here for Employment verification form

HOW DO I FILL OUT THIS FORM?

You will fill out the first part of the form(section A). Have your or your spouse’s employer(whichever provides insurance coverage to you)fill in the second part of the form(Section B) and sign it.

WHAT TO DO WITH THE COMPLETED FORM:

Once both sections are complete, you need to include the form with your Medicare enrollment application. You send both forms to your local Social Security office.
If you need to find your local Social Security office click here, after you get to the page you click on the menu. Then click on contact us, and finally click on find an office.

If you have any questions or need help with this, please contact our office. You can reach us either by phone (203)796-5403 or by email at [email protected]

If you are a Medicare agent and need a scope of appointment form Click Here.

Preventive care definition

By ecrowe | General Articles | 0 comment | 19 July, 2018 | 0

Preventive care definition

This post will help you to better understand what the Preventive care definition is. This will give you an idea of what your health care coverage is providing to you and sometimes what it is not.

The care that you receive to prevent illness or disease is referred to as preventive care. This can also include counseling you receive in an effort to prevent health problems. The reason insurance companies provide these services at no cost to you is because; if you are healthy it costs them less to provide insurance coverage for you in the long run. The basic idea is that getting preventive care, such as screenings and immunizations, helps keep you and your family healthy. All Marketplace health plans as well as many other health plans are required to cover preventive services without charging you either a copay or coinsurance. This applies even if you have not met your yearly deductible yet.

The Preventive care list includes different services if you are an adult than the services that qualify as preventive if you are a child. The insurance industry also bases preventive care on the risk factors for each individual. These factors vary according to both your family history as well as your personal history.

CLICK THIS LINK TO VIEW THE ACA LIST OF PREVENTIVE CARE SERVICES

If you need assistance with obtaining insurance, please contact us. You can reach us either by phone at (203)796-5403 or by email at [email protected] We are always happy to assist clients in finding the best coverage options available to them.

Medicare forms online

By ecrowe | General Articles | 0 comment | 13 July, 2018 | 1

Medicare forms online

Medicare forms online can help you search for a Medicare form to file a claim, request an appeal, or for Medicare to give someone access to your personal health information?

To get the Medicare form you need, visit Medicare.gov and find the situation that applies to you.

Maybe you’ve been working past the age of 65, have had health coverage through your (or your spouse’s) employer, and are now ready to enroll in Medicare Part B. If so, you’ll most likely need to fill out CMS forms 40B and L564 and take those to your local Social Security office to start Part B coverage. You can find those particular forms on Medicare.gov, too, under “Enrollment Forms.”

To get the Medicare form you need, find the situation that applies to you. Get forms in alternate formats.

I want to make sure Medicare can give my personal health information to someone other than me (Authorization to Disclose Personal Health Information form/CMS-10106).

I want to file a claim for services and/or supplies that I got (Patient Request for Medical Payment form/CMS-1490S).

I want to start, stop, or change bank accounts for automatic monthly deductions of my Medicare premium (Authorization Agreement for Pre-authorized Payments form/SF-5510).