Application to cancel your SASMI premiums paid to your Health Plan from your HCRA.
SASMI will cancel your premium payments based on the information you provide below.

This payment(s) will continue until you formally submit a request to cease payments.

Funds will be deducted from your HCRA account as directed (monthly/quarterly) and sent directly to your health care provider.

For any questions, please email us at: OFFICE@SASMI.ORG

Email address *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy