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Assumption of Responsibility for Electronic Data

 

This form is required if the group is requesting access to the Employer Connection, Delta Dental of Arizona’s secure, online portal for group administration and billing.

All items must be completed to submit form.

Group Information

  Group Name
  Submitted by (Contact Name)
  Contact Email Address

Please choose your preferred method for receiving billing statements (select one)

  Paper Notification Only available to groups with 10+ enrolled
 
  Email Notification
Email address to receive billing statement
Required for groups with 2-9 enrolled; Optional for groups with 10+ enrolled
 
  Fax Notification
Ten Digit Fax Number
Only available to groups with 10+ enrolled

Authorized Signature

 

Delta Dental of Arizona (DDAZ) groups may submit electronic eligibility files instead of paper enrollment forms. Groups may also view billing records online.

By selecting "I Agree" below, I warrant to DDAZ, that the group indicated above (the Group) is responsible for this data entry. I also certify that I am an authorized representative of the Group and that I have the authority to make eligibility changes. If Group granted online access to an Agent/General Agent of Record on the Employer Group Master Application, I acknowledge that the Agent of Record has the authority to make eligibility changes. I agree that any errors contained in the eligibility files are the responsibility of the Group. Common errors include spelling errors, which may translate into billing adjustments. I understand that there may be an additional cost associated with the changes submitted, even if the change was in error or unintentional. I agree on behalf of the Group to pay for any additional costs associated with my changes. I also agree that the Group is responsible for notifying DDAZ to remove online access for any authorized user, including the Agent/General Agent of Record.

I agree to the above terms and conditions.

 


Please enter the form authorization code in the text box below.

 
  
 
   

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