Name
*
Email
*
Case Number
*
Customer Onboarding
1. ACH Enrollment
Method for ACH information submission
*
Please Select
Secure Online Form
Editable PDF ready for email
Download, Print, Complete & Email
Please download and complete the following
ACH Enrollment Form here
.
Complete out the form, scan it and email it to:
ar@roedentallab.com
Legal Entity Name / Name on Bank Account
*
Doing Business as Name (if different from legal entity name)
Physical Address on File with the Bank
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Accounts Payable Contact Name
*
Accounts Payable Email for Confirmation Notices
*
Finicial Institution Information
Name of Financial Institution
*
Address of Financial Institution
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
9 Digit Routing (ABA) Number (Domestic ACH)
*
Account Number
*
Approval for ACH Payment
Submitter's Name
*
Submitter's Title
*
Submitter's Phone Number
*
This is to notify ROE Dental Laboratory, Inc. and/or one or more of its subsidiaries and affiliates (herein collectively called ROE) of enrollment or change in EFT/ACH banking instructions for the Company (name stated below) herein referred to as Company. Therefore Company authorizes ROE to debit the noted account for accepting payments for goods and services by ACH. In the event of any duplicate payment, overpayment, fraudulent payment or payment made in error, the receiving party will immediately return such payment upon confirming the occurrence of any of the foregoing.
*
I agree
2. Communication Preferences
The same information can be used on multiple lines below if appropriate.
Doctor Preferred Method of Communication
*
Please Select
Email
Call Office
Best Office Phone Number
*
Accounting Phone Number
*
Technical Email
*
Scheduling Email
*
Accounting Email
*
IOS in office
*
Please Select
3Shape Trios
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Shining 3d
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