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 Member(s) Covered by Dental Savings Plan Click here if Financially Responsible Party is a memberMember | 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 Number 0000* -0000*-0000*- 0000*
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.