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How do I fill this out?
To fill out this form, begin by reviewing your bank information carefully. Ensure that you provide the correct details for automatic withdrawals. Finally, submit the completed form to enable the payment process smoothly.
How to fill out the Delta Dental Automatic Payment Setup?
1
Review the Authorization for Payment Form.
2
Enter your bank details including bank name, transit number, and account number.
3
Include a voided check for verification.
4
Sign and date the form.
5
Submit the form via fax or mail to Delta Dental.
Who needs the Delta Dental Automatic Payment Setup?
1
Employer groups enrolled with Delta Dental need this form to enable automatic payments.
2
HR representatives require this form to set up dental premium payments.
3
Financial officers within companies need the form to manage budgeting for employee benefits.
4
Any designated personnel managing health accounts need this for smooth payment transactions.
5
New groups enrolling with Delta Dental require this to start automatic payments.
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What are the instructions for submitting this form?
To submit the completed Authorization for Payment Form, please fax it to Delta Dental at 877-439-8841. Alternatively, you can mail the form along with a voided or canceled check to Delta Dental of Kentucky, Inc., PO Box 242810, Louisville, KY 40224-2810. Ensure that you complete the form and submit it by the 10th of the month for your account to be activated for payments starting the following month.
What are the important dates for this form in 2024 and 2025?
For 2024, ensure submissions are made before the 10th of each month for payment on the 1st. Maintain timely updates to avoid service interruption. Each year, keep an eye on changing deadlines that may arise.
What is the purpose of this form?
The purpose of this form is to facilitate automatic bank draft payments for dental premiums. Employer groups enrolled in Delta Dental can authorize payments directly from their checking accounts. This process not only simplifies premium payments but also aids in maintaining financial efficiency.
Tell me about this form and its components and fields line-by-line.
- 1. Bank Name: The name of the financial institution from which payments will be drawn.
- 2. Transit Number: A unique identifier for your bank for routing purposes.
- 3. Account Number: Your specific account number linked to the bank.
- 4. Company Name: The name of the employer group that is being authorized for payments.
- 5. Authorized Signature: Signature from the authorized representative of the group.
- 6. Date: The date when the form is signed.
What happens if I fail to submit this form?
Failing to submit this form may result in delayed payments or service interruptions. It is essential to complete the authorization to ensure timely withdrawals. Without a valid authorization, payments will revert to the standard process.
- Payment Delays: Payments may not be processed on time, affecting coverage.
- Reversion to Manual Payments: Without the form, manual check payments will be required, which could lead to delays.
- Coverage Interruption: Failure to pay on time could result in interruptions to dental benefits.
How do I know when to use this form?
- 1. Setting Up Automatic Payments: Use this form to enable automatic withdrawals for premium payments.
- 2. Managing Group Benefits: HR departments will use it to manage dental benefits effectively.
- 3. Updating Payment Information: Update bank details through this form as needed.
Frequently Asked Questions
What is the purpose of this form?
This form enables automatic payment withdrawals for dental premiums.
How do I submit the form?
You can submit the form via fax or mail it to the specified address.
Do I need to include a voided check?
Yes, including a voided check is necessary for verification.
When will the withdrawals occur?
Withdrawals will take place on the first of each month.
Who is eligible to use this form?
Any enrolled employer group with Delta Dental can use this form.
How can I edit this PDF?
You can easily edit the PDF using PrintFriendly's editing tools.
Is there customer support available?
Yes, customer support is available for any inquiries.
What happens if I miss the submission deadline?
The withdrawals will not be activated until the next cycle.
Can I cancel my authorization?
Yes, you can notify Delta Dental in writing to cancel your authorization.
Will the online enrollment affect my bill?
Yes, changes made through online enrollment will reflect on the next bill.
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