Third-Party Payment Authorization
Resident Information
Resident Name
Date of Birth
Facility Name
Facility Address
Third-Party Payer Information
Organization/Person Name
Relationship to Resident
Address
Phone Number
Email
Authorization Details
Payment Coverage (describe what fees/charges will be covered)
Authorization Effective Date
Authorization End Date
Terms & Conditions
Resident/Legal Representative Signature
Date
Third-Party Payer Signature
Date