Electronic Funds Transfer / Direct Deposit Enrollment Form

All fields must be completed unless otherwise noted. For additional information, point your mouse to the info icon () next to each field.
Please click here to download written instructions for this form.


Provider Information


* Provider Name:
 
Provider Address
*
 
* City:
 
* State/Province
 
* Zip Code / Postal code
 


Provider Identifiers Information


Provider Identifiers
* Provider Federal Tax Identification Number (TIN) or Employer Identification Number (EIN):
 
National Provider Identifier (NPI) (when Provider has an NPI):


Provider Contact Information


* Provider Contact Name:
 
* Title:
 
* Telephone Number:
 
Telephone Number Extension (if applicable):
Fax Number (if applicable):
Email Address (if available):


Financial Institution Information


* Financial Institution Name:
 
* Financial Institution Routing Number:
 
* Type of Account at Financial Institution:

 
* Provider's Account Number with Financial Institution:
 
* Account Number Linkage to Provider Identifier:

 
 


Submission Information


* Reason for Submission:


 
Include with Enrollment Submission:

 
(A letter on bank letterhead that formally certifies the account owners' routing and account numbers)

Authorized Signature

In consideration for the provision of direct deposit services, by signing below, I authorize Electronic Funds Transfer from Delta Dental of New Jersey, Inc. (on behalf of Delta Dental of New Jersey, Inc., other Delta Dental member companies and their affiliates) to direct payments to the bank account indicated above.
 
I understand that (a) this authorization extends to all payments due to this Authorizing Entity for all providers associated to its TIN or EIN and at the service office(s) listed above; and (b) the information provided above is subject to an audit at the discretion of Delta Dental of New Jersey, Inc.
 
Delta Dental member companies and their affiliates will not be responsible for any damages, or any fee, charge or other expense assessed against the Bank Account identified above, in connection with this direct deposit program.
 
This authority is to remain in full force and effective until Delta Dental of New Jersey, Inc. receives written notification from the authorized signee of its termination in such time and manner as to afford Delta Dental of New Jersey, Inc. reasonable opportunity to act on it.
* Electronic Signature of Person Submitting Enrollment:
 
* Printed Name of Person Submitting Enrollment:
 
Submission Date:   09/15/2019




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