Credit Card Authorization Form

This form has been created in order for 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. 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:


City: State: Zip Code:


Card Holder Information


Phone Number:


City: State: Zip Code:



Relationship to Cardholder:

Credit Card Information

Please fill out credit card information below and specify the purpose of use for the card (i.e., treatment, incidental charges, pharmacy charges, etc.) Additional lines are provided if you would like to use separate cards for different purposes.

Credit Card#: Name on Card: Card Type: Exp Date: Sec. Code: Purpose for Card

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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Forms - Cirque Lodge Alcohol and Drug Rehab Center
Signature Certificate
Document name: Credit Card Authorization Form
Unique Document ID: 9c6b56bca5e516006ae569ba28465692aafcbc03
Timestamp Audit
July 27, 2016 8:57 am MSTCredit Card Authorization Form Uploaded by Courtney McShay Carroll - IP