Medical Alarm, Medical Alert by AlertAngel "..just $9.95 MONTHLY"- AARP Safest Elderly Senior Personal Emergency Medical Alert Medical Alarms Monitoring System Device Service

UPDATE MY BILLING INFORMATION

The form below is to update your billing information only. Allow 24 hours during normal business for the information to be updated.

UPDATE BY MAIL

If you prefer to update any account information by mail, just call us at our toll free number and we will mail you the forms to fill out and return to us.

Please Read Before Submitting:

The billing information will completely replace all current billing information.
Complete all sections of this form and double check you information for accuracy.

Client Information

Important: This information must be provided before we can process the changes.

( * ) Asterisk indicates a required field.

* Client's 10-Digit Phone Number (Include Area Code)

* Client's Full Name (Person Using Monitor)

* Your Full Name (Person Completing Form)

* Your Phone Number (Include Area Code)

Your Email Address

I WANT TO UPDATE THE FOLLOWING BILLING INFORMATION:

Fully Complete only the sections that apply.

For Example:: If you are only changing the credit card information, just fill out "Person Who Pays Bills" and "Credit Card Information" sections. Skip the "Checking Account Information" section.

Person Who Pays Bills

I am providing completely new information for the Person Who Pays Bills. This information is associated with the payment method below.

First Name
Last Name
Address 1
Address 2 (apt #)
City
State
Zip Code
County/Township
Phone Number	(Include Area Code)
Email

Credit Card Information

I am providing completely new credit card information. It will replace all current information.

IMPORTANT: Only show name as it appears on Card:

First Name
Middle Initial	(only if on card)
Last Name
Card Type
Card Number	(no dashes or spaces)
Expiration Date	/

Automatic Check Payment Information

I am providing completely new bank account information. It will replace all current information.

IMPORTANT: Only show name as it appears on Check:

First Name
Middle Initial	(only if on check)
Last Name
Bank Name
Routing Number	(9 digits only)
Account Number

Any special instructions with this updated billing information? (Optional)

NONE

I agree that by submitting this form I am authorized to make changes to this account and I accept sole responsibility for any errors, inaccuracies, or omissions with the information provided. I also agree not to hold the Medical Alarm Company responsible for any damages or liability as a result of this information.

I(we) have read, understand and agree with the statement above

(Required)

(Click Once Only)

UPDATE BY MAIL

If you prefer to update any account information by mail, just call us at our toll free number and we will mail you the forms to fill out and return to us.