Electronic Funds Transfer/Direct Deposit: Dentists EFT/ERA Option Preference for Aggregation of Remittance Data: Clearinghouse Name (Check One) Vendor Name (Please provide the name

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Delta Dental of Arizona | 5656 W. Talavi Blvd. Glendale, AZ 85306 | 602.938.3131 | Toll-free: 800.352.6132 | deltadentalaz.com

Delta Dental of Arizona

Electronic Funds Transfer/Direct Deposit: Dentists

Network dentists can opt in to direct deposit, allowing for quicker and safer electronic payment of Delta Dental claims. Direct deposit is a free service and is available locally and/or nationally.

General Instructions If you have multiple offices and would like direct deposit for each location, you must complete a form for each office location. Accuracy of all information is essential. If you have any questions, please contact Delta Dental of Arizona’s Professional Relations Department at 800.352.6132.

National EFT/ERA Enrollment If you wish to receive all payments for Delta Dental Member Company claims via direct deposit, you must opt in to National EFT/ERA Enrollment. Explanations of Payments will be delivered as a National Electronic Remittance Advice (ERA) and can be accessed via the Dentist Connection.

Participation in National EFT/ERA is limited to dentists whose project management software uses ERA with the Emdeon or DentalXChange clearinghouses.

Late or Missing EFT If your expected EFT appears to be late or missing, please contact Delta Dental of Arizona’s Professional Relations Department at 800.352.6132 or [email protected]. You will need to contact the appropriate Delta Dental for out-of-state issues.

Submitting Your Completed Enrollment FormSubmit your completed form and voided check or bank letter to:

If you are not an Arizona office, you must contact your local Delta Dental for enrollment.

Delta Dental of ArizonaProfessional Relations Department5656 W. Talavi Blvd.Glendale, AZ 85306Toll Free: 800.352.6132Fax: [email protected]

Provider InformationProvider Name

Provider Address

City State Zip Code

Financial Institution InformationFinancial Institution Name Financial Institution Telephone Number

Financial Institution Routing Number Checking Savings

Provider’s Account Number with Financial Institution Account Number Linkage to Provider Identifier¹

Submission InformationReason for Submission

Include with Enrollment Submission (Check One)

Provider Identifiers InformationProvider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)

National Provider Identifier (Individual Provider - NPI 1) National Provider Identifier (Organizational Provider - NPI 2)

Provider Contact InformationProvider Contact Name

Telephone Number Email Address

New Enrollment Change Enrollment Cancel Enrollment

¹Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN)

²A letter on bank letterhead that formally certifies the account owners routing and account numbers

Voided Check Bank Letter²

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Authorized Signature

Submission Date Requested EFT Start/Change/Cancel Date

_______________________________________________________________Written Signature of Person Submitting Enrollment

_______________________________________________________________Printed Name of Person Submitting Enrollment

This authority is to remain in full force and effective until Delta Dental of Arizona Inc. receives written notification from me/us of its termination in such time and manner as toafford DDWI reasonable opportunity to act on it.

National EFT/ERA Option

Preference for Aggregation of Remittance Data:

Clearinghouse Name (Check One)

Vendor Name (Please provide the name of your practice management software vendor.)

Delta Dental of Arizona Administrative Use OnlyDentist License Number State Office Location Number or Clinic Number

DDAZ Representative Initials Date

Delivery Option

Email to receive direct deposit notification

Email notification with delivery of Explanation of Payment to Delta Dental’s website

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Emdeon® DentalXChange

Remittance Data is aggregated by Provider Tax Identification Number (TIN).

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Delta Dental of Arizona offers the Delta Dental National EFT option. Participation in Delta Dental National EFT affords you access to EFT with all participating Delta Dental member companies through this one enrollment form.

In consideration for the provision of direct deposit services, by signing below, and notwithstanding any language to the contrary herein, you hereby acknowledge and agree that (i) any information you have provided, including but not limited to, the information you supplied under the heading “Banking Information” above, may be transferred, shared or otherwise provided by us to or with any entity that is an affiliate of Delta Dental, as defined above, with other Delta Dental member companies and their affiliates, and with Delta Dental Plans Association, for use in connection with funds to be deposited to your account, (ii) any election to discontinue enrollment in this direct deposit program will take up to 30 business days to process, and may not be effective to halt any deposits that were initiated while your enrollment in this direct deposit program was in effect, and (iii) in the absence of gross negligence or willful misconduct, neither we, any of our members and affiliates, other Delta Dental member companies and their affiliates, or Delta Dental Plans Association, will be responsible for any damages, or for any fee, charge or other expense assessed against the Bank Account identified above, in connection with this direct deposit program.

Further, by signing below, you represent and warrant that (i) all of the information you supplied is true and accurate, (ii) the information provided under the heading “Banking Information,” above, identifies a bank account held by the Business you identified above, and (iii) the signatory to this Direct Deposit Enrollment Form (“Form”) has all necessary power and authority to execute this Form. I hereby elect participation in the Delta Dental National EFT solution.

_______________________________________________________________Written Signature of Person Submitting Enrollment

_______________________________________________________________Printed Name of Person Submitting Enrollment

Documents

Electronic Funds Transfer/Direct Deposit: Dentists EFT/ERA Option Preference for Aggregation of Remittance Data: Clearinghouse Name (Check One) Vendor Name (Please provide the name