Credit Card & Pharmacy Authorization Form


This form has been created in order for third party expenses to be charged to your credit card including pharmacy charges. Please provide all the information requested below to ensure prompt processing of your application. We ask you to please send admissions a photo/copy of your credit card, insurance card and picture ID. Please sign and date the form before submission and email or fax additional information to Cirque Lodge at (801) 222-0112.

Resident Information

Name: Gender:

Phone Number: SSN: Birth Date:

Address:

City: State: Zip Code:

Relationship to Cardholder:

Harmon’s Pharmacy Authorization

PLEASE NOTE: If the insurance information is incomplete, we will be unable to bill your insurance for pharmacy charges and we will use the credit card as the form of payment.

Insurance Company Name:

Policy Holder’s Name (As it appears on the card):

ID#:

Pharmacy Name Previously Filled @:

Pharmacy Phone Number: Medication Allergies:

I hereby authorize Harmon’s Pharmacy to collect payment on all charges incurred by the above referenced resident which are not covered by insurance by processing a charge to the credit card listed below. I agree and guarantee to pay in full any indebtedness, obligation and/or liabilities owing to Harmon’s by the abovementioned resident, including, but not limited to copayments and self-payments for medication, supplies, and/or miscellaneous charges including finance charges or collection fees.

Card Holder Information

Name as is appears on Credit Card:

Credit Card Type:

Account Type:

Company Name:
Account #: Exp Date: Security Code:

Address (where statement is mailed):

City, State and Zip:

Phone Number:

I certify that I am the listed cardholder and that all information is complete and accurate. I hereby authorize Cirque Lodge, and any third party entities associated with Cirque Lodge (such as Harmon’s Pharmacy) to collect payment on all charges incurred by the above referenced resident which are not covered by insurance by processing a charge to the credit card listed above. I agree and guarantee to pay in full any indebtedness, obligation and/or liabilities owing to Cirque Lodge and/or its agents by the above referenced resident, including, but not limited to treatment cost, medical copayments, copayments and/or self-payments for medication, supplies, lab tests, shipping costs, therapeutic books, phone cards, salon and massage services, dry cleaning, Cirque apparel, fishing licenses, outpatient counseling sessions and/or miscellaneous charges including finance charges or collection fees.

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Signature Certificate
Document name: Credit Card & Pharmacy Authorization Form
Unique Document ID: d4aa9a9f5f56d8c457241545c7216ab7f0b80998
Timestamp Audit
April 22, 2016 8:43 am MSTCredit Card & Pharmacy Authorization Form Uploaded by Courtney McShay Carroll - information@cirquelodge.com IP 205.204.44.102