Delta Dental of Arizona

Electronic eCheck Payments

It's easy and convenient way to pay by electronic means from your bank account. Please enter the following information from your check or bank statement. Incomplete or incorrect information may result in our inability to proceed with its request for payment.

Please complete all form fields.


Step 1 - Company / Account Holder Information  

Company
Enter "None" if not applicable
 
First Name
Last Name
Address
City
State
ZipCode
Telephone
Email Address

Step 2 - Transaction Classification
 
Transaction Type  
ID or Group Number
Notes or Comments

Step 3 - Financial Institution


Name of Financial Institution
Check Number
(Enter "0" if unknown)  (Numbers Only )
9 Digit ABA Routing Number  (Numbers Only )
Account Number  (Numbers Only )
 

Step 4 - Transaction Amount

Currency: U.S. Dollar ($)   -   $2,500.00 Maximum
Transaction Amount
Accept Transaction Amt  
I understand that any EFT transactions that are dishonored by my financial institution intended for payment to Delta Dental of Arizona will be assessed a $25 service charge.

Submit Transaction

Press the submit button ONCE.  Multiple submissions could result in multiple charges.

 

 

Delta Dental of Arizona 5656 W. Talavi Blvd, Glendale, Arizona USA 85306
© Copyright 2020 Delta Dental Plans Association and Delta Dental of Arizona
All Rights Reserved.