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Please fill out the form below to make a payment for your Covered California dental coverage through LIBERTY Dental Plan. You also have the option to click here to print the form and mail your payment. Please note that checks should be made payable to LIBERTY Dental Plan.

The payment deadline is Wednesday, March 8 for March coverage.


Mail To:
LIBERTY Dental Plan of California
PO Box 26110
Santa Ana, CA 92799-6110

Is this your first time making a payment for your plan?

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Subscriber

Contact Information

Enrollment Details

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Billing Information

The name and address entered must match the name and address on file with your bank or credit card account.


Never miss a payment! Turn on automated recurring payments.


The automated payment feature will deduct your monthly premium due on the 10th of every month to the billing account provided above. The first automated payment of $0 will be deducted on the 10th during your first month of coverage.

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To verify you are not a robot, please type the phrase below.

Payment Information

(Pay to LIBERTY Dental Plan)
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Never miss a payment! Turn on automated recurring payments.


By checking YES, the automated payment feature will deduct your monthly premium due on the 10th of every month to the billing account provided above. The first automated payment of $0 will be deducted on the 10th during your first month of coverage. Your authorization will remain in effect until the end of the current coverage year or until you notify LIBERTY Dental Plan in writing with your request to cancel.


I authorize LIBERTY Dental Plan to charge the Total Amount Owed to the payment method selected above.

I understand that eligibility will begin on the proposed effective date, pending enrollment confirmation from Covered California and successful payment processing.