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Assumption of Responsibility for Electronic Data

 

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

By checking the yes box below, I warrant to DDAZ, that the group indicated below (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. 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.

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    
    Email Notification  
  Email address to receive billing statement
   
  Fax Notification    
  Ten Digit Fax Number
   
 

Authorization

 

I agree to the above terms and conditions.

 


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

 
 
 
   

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