Guarantor Form
Facility Name:
*
Resident Name
*
First Name
Last Name
Responsible Billing Party
(Guarantor)
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Guarantor's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Payment
I will pay by
*
Credit Card (Bill will be paid automatically by credit card monthly)
Check
Credit Card #
Expiration Date
Security Code
ACKNOWLEDGEMENT OF HIPAA GUIDELINES AND AUTHORIZATION TO UTILIZE GREAT NECK CHEMISTS, INC. OF N.Y. DBA PRECISION LTC PHARMACY. I UNDERSTAND THAT THIS ACCOUNT IS TO BE PAID IN FULL EACH MONTH. THE GUARANTOR IS RESPONSIBLE FOR ALL SUCH PAYMENTS. IF PAYMENT IS NOT RECEIVED WITHIN 60 DAYS OF STATEMENT DATE, WE RESERVE THE RIGHT TO REFUSE SERVICE.
Signature
*
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