Delta Dental of Arizona   (Select your state)
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Automated Clearinghouse Authorization Agreement For Preauthorized Payments

Delta Dental of Arizona requires small groups and renewing groups to make premium payments via ACH. As a courtesy to clients, an account for the Employer Connection will automatically be created for you. Please review the steps below and keep in mind that the accuracy of information is essential.

  1. Complete the form below to begin the ACH process.
  2. ACH withdrawals will begin for the billing cycle after the form is received.
  3. Invoices are run on the 15th of each month. You will receive an email around the 17th of each month that will include basic information on the amount of the withdrawal. You will need to log in to the Employer Connection to view the invoice.
  4. Premium payments are withdrawn on the first business day of the month.

** Denotes fields that accept only numeric values.

Group Contact Information

  Dental Group Number
  Vision Group Number
  Group Name as it appears on the Invoice
  Taxpayer Identification Number**
  Group Contact Name
  Group Contact Telephone**
  Group Contact Email

ACH Information

  Depository Contact
Depository Contact Phone **
 

Financial Institution

  Name of Financial Institution
  Bank Telephone Number**
  Bank Account Number** Account Number
Re-Enter Account Number
  Bank Routing Number** Enter Route
Re-Enter Route
 
  Account Type Checking Savings
(Delta Dental of Arizona will keep all financial information secure and confidential.)
 
    I agree to the ACH Authorization terms and conditions.

I (we) hereby authorize Delta Dental of Arizona (the "Company") to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any debit entries in error to my account and the financial institution indicated below, (the "Depository"), to debit and/or credit the same such account.

This authority is to remain in full force and effective until Delta Dental of Arizona Inc. (DDAZ) and said financial institution have received written notification from me of its termination in such time and manner as to afford DDAZ and said financial institution reasonable opportunity to act on it.

Employer Connection Sign Up

Delta Dental of Arizona (DDAZ) small groups are required to use the Employer Connection for eligibility updates and to view invoices.

  Select if same as Group information above
  Dental Group Number
  Vision Group Number
  Group Name as it appears on the Invoice
  Group Contact for Electronic Data
  Group Contact Email for Electronic Data
  Does your group already have an Employer Connection login?
 
    I agree to Electronic Data terms and conditions.

By checking the "I Agree" box , I warrant to DDAZ, that the group indicated on this form (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.

Security Code

 


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

 
 
 
   

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