Delta Dental of Arizona

Please enter the following information exactly as it appears on your credit card statement.  Incomplete or incorrect information may result in our inability to proceed with your payment request. It's easy and convenient to pay by credit card. You can use your MasterCard, Visa or American Express Card. 

Please complete all form fields.


Step 1 - Cardholder Information  
First Name
Last Name
Billing Address
City
State
ZipCode
Telephone (Numbers Only)
Email Address for Confirmation

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

Step 3 - Credit Information
Credit Card Type  
Account Number (Numbers Only)
Security Code
Expiration Date /
 

Currency: U.S. Dollar ($)   -   $2,500.00 Maximum
Invoice Amount Due
Accept Transaction Amt
*Group transactions will include a 5% Processing Fee

Step 4 - Submit Transaction

Refund and Return Policy: If you purchased a new individual policy, you have 14 days from the date your enrollment confirmation letter was produced and mailed to cancel your policy and receive a full refund of the premium. Additional cancellation and refund details can be found in your dental or vision contract. In the event of a conflict or inconsistency between this webpage and the contract, the terms of the contract shall prevail.

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.