Electronic Funds Transfer (Eft)/direct Deposit Authorization Agreement Form

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Delta Dental of Tennessee
Electronic Funds Transfer (EFT)/Direct Deposit Authorization Agreement
SECTION A
INSTRUCTIONS
Please complete Sections B, C and D and return this Electronic Funds Transfer (EFT)/Direct Deposit Authorization Agreement
(“Agreement”) along with a “VOIDED” check to the following address:
Professional Relations
Delta Dental of Tennessee
240 Venture Circle
Nashville, TN 37228-1699
FAX 615-742-6940
SECTION B
BUSINESS INFORMATION
(PLEASE TYPE OR PRINT)
Authorized Account Holder’s Name _________________________________________________________________________
Business Name __________________________________________________________________________________________
Business Address ___________________________________ City __________________ State ____ ZIP Code _________
Business Tax Number
______________________________________________________________
(number used for IRS reporting)
Phone Number ( _____ ) _____________ Fax Number ( ______ ) _____________ E-mail Address ____________________
SECTION C
BANK OR FINANCIAL INSTITUTION INFORMATION
PLEASE ATTACH A “VOIDED” CHECK
Name of Account
_______________________________________________________________
(as it appears on checking account)
Bank or Financial Institution Name _________________________________________________________________________
Address ____________________________________________ City _________________ State ____ ZIP Code _________
Phone Number ( ____ ) _____________ Routing Number ____________________ Account Number _________________
SECTION D
AUTHORIZATION STATEMENT
By signing below, I request and authorize any Delta Dental in accordance with my Participation Agreement, Uniform Requirements
and applicable DeltaUSA policies and procedures to deposit funds for claim payments directly into the Bank or Financial Institution
account as specifi ed in Section C, and agree to the following:
1. The effective date for electronic funds transfer will be at least fi fteen (15) days from the date the Delta Dental stated in Section A
receives the completed and signed Agreement;
2. That all account changes in Section C instituted by Bank or Financial Institution require fi fteen (15) days prior written notice sent
to the address stated in Section A. Upon receipt of said written notice by the Delta Dental stated in Section A, the written notice
will be considered an amendment to this Agreement;
3. That termination of this Agreement requires fi fteen (15) days prior written notice along with the effective date of the termination
and reason for termination (i.e.: account closed; changing accounts), sent to the Delta Dental stated in Section A;
4. That all account changes instituted by Business Name as stated in Section B require fi fteen (15) days prior written notice, in
addition to providing the following: (1) a voided check; and (2) the signing of a new Agreement sent to the Delta Dental stated in
Section A; and
5. That the Delta Dental stated in Section A may terminate this Agreement at any time without cause.
____________________________________________________________________
_______________________________
Signature of Authorized Account Holder
Date Signed
RETAIN A COPY OF THIS COMPLETED AGREEMENT FOR YOUR RECORDS
EFTauthTN 07/06

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