Superior Dental Care Secure Form
Use this form to have your claim reimbursement payments automatically
deposited into the account of your choice.
AUTO DEPOSIT PROGRAM
Participating Dentist Name:  
Tax ID Number:  
(A separate form is needed for each TIN)
Office Location:  
Name on the Account:  
Account Number:
   
(Re-Enter)  
Type of Account:
Financial Instituition Name:  
Address:  
Routing and Transit Number:  
Name of Authorized Person:  
Fax Number:  
Email Address:  
The provided email address will be used for release of Claim Voucher Statements associated with the Auto Deposit.
Please use our Document Upload to securely send a copy of a voided check (required).
By entering my initials in the box below, I certify that I am an authorized representative of the company identified on this form and that any information submitted is accurate and current.
Initials: