Change Method of Premium Payment

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Any requests to change your Method of Premium Payment submitted after the first of the month will not be reflected in the following months deduction.

Effective Date

Change Method

(ERB retirees are required to select option 2, automatic bank draft, if changing the method of payment)

I authorize a deduction from my pension earnings for NMRHCA insurance plan contributions I authorize an automatic bank draft on my checking account for NMRHCA insurance plan contributions

Download your documentation file

Please send the documentation file, along with a payment (check, cashier's check or money order made payable to the NMRHCA) to:
6300 Jefferson St. NE
Suite 150
Albuquerque, NM 87109

Authorization for Deduction / Method of Payment

By selecting the boxes below, I acknowledge that:

Participation in the New Mexico Retiree Health Care Act is subject to specific eligibility requirements and that benefits offered through the New Mexico Retiree Health Care Authority are subject to legal limitations. Ineligible individuals cannot receive benefits through this program and will benefits or services will not exceed legal limitations. Submitting information on this page is only an application for benefits and does not create any contractual relationship or impose any duties on the part of the New Mexico Retiree Health Care Authority. I must comply with all program requirements, including making timely payments, to enroll and participate. I agree that the New Mexico Retiree Health Care Authority may terminate my participation in this program for noncompliance. I have carefully read and understood all statements on this page and included with this submission, approve all indicated changes, and elect the coverages and benefits selected. I am the actual person applying for benefits whose signature appears below or I am signing on another's behalf under a power of attorney. (If I am signing on another's behalf under a power of attorney, I have attached current authorizing documents or ensured that the New Mexico Retiree Health Care Authority has current authorizing documents on file.)

By typing my name in the space provided below, I hereby declare that all the information I have provided in connection with this application is true and complete to the best of my knowledge.

Type full name in the box below

Today's Date

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