Dental Savings Plan - Payment Update Form

Recurring Payment Update Form

Thank you for being a Dental Savings Plan member!

To update the card information for your membership, please fill out all required fields below. Then, click "Submit" once completed.
Name of Financially Responsible Party *

First Name Last Name
Name of Member(s) Covered by Dental Savings Plan

Click here if Financially Responsible Party is a member

Member |   First Name   Last Name
Member |   First Name   Last Name
Member |   First Name   Last Name
Member |   First Name   Last Name
Member |   First Name   Last Name

Card Details
Name On Card *

First Name Last Name
Card Number
Card Number
Card Number 0000* -0000*-0000*- 0000*
Expiration Date *
CVV *
Your payment will now be processed on either the 1st or 15th of each month. Please choose your preferred option.

1st of the Month 15th of the Month
I First Name* Last Name* hereby authorize Real Life Dental Billing to continue recurring monthly debit entries from my account according to the Dental Savings Plan Annual Membership Agreement and Authorization. If the day of payment falls on a weekend or bank holiday, the withdrawal shall occur on the next business banking day.

I agree to pay the total amount according to the card issuer agreement and authorize debit entries from my account.

Notification to modify, cancel and/or revoke this authorization is required. You must contact Real Life Dental Billing (billing@reallifedental) prior to the next scheduled debit.
Signature *

Clear

Questions and Comments
If you have any questions or comments, please let us know. We appreciate your feedback.
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