Credit Card Authorization Form - Julia Himberg
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.
Name: Amy Himberg Gender:
Phone Number: 385-448-7844 SSN: Birth Date: 11/25/1982
Address: 341 N 1100 East
City: American Fork State: UT Zip Code:
City: State: Zip Code:
Relationship to Cardholder: Sister
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|
|4815831016469806||Julia Himberg||03/21||313||Cirque final payment|
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.
|January 3, 2018 11:09 am MDT||Credit Card Authorization Form Uploaded by Courtney McShay Carroll - firstname.lastname@example.org IP 18.104.22.168|
|January 3, 2018 11:09 am MDT||Document sent for signature to Julia Himberg - email@example.com|
|January 3, 2018 11:30 am MDT||Document signed by Julia Himberg - firstname.lastname@example.org IP 22.214.171.124|
|January 3, 2018 11:30 am MDT||The document has been signed by all parties and is now closed.|