PAYMENT RECEIPT FORM
PATIENT NAME: SIGNATURE: PAYMENT METHOD: CASH CHECK DATE:
330 Lexington Drive, Buffalo Grove, IL 60089 Phone: 847-495-7000; Toll Free: 866-353-3746 Fax: 847-495-7090 Hours 9-5PM CST www.plannedeldercare.com; info@plannedeldercare.com
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TOTAL AMOUNT PAID: NUMBER: BANK NAME: ACCT NUMBER:
$
BANK ROUTING NUMBER: CREDIT CARD
□
TYPE: VISA
□
MASTERCARD
□
AMERICAN EXPRESS EXP DATE:
□
CARD NUMBER:
Outside Rep Name: _______________________________________ Outside Rep Fax: ______________________________________ Privacy Policy and Disclosure: This Policy explains what Planned Eldercare, Inc. does to keep information about you private and secure. We want you to know how we manage the information to serve you. We take a number of steps to protect the privacy of information about you. We keep information under physical, electronic or procedural controls that comply with or exceed governmental standards. We authorize our employees, agents and contractors to get information about you only when they need it to do their work for us. This Policy applies to current and former customers. This policy is effective as of December 1, 2007.
PAYMENT RECEIPT FORM
PATIENT NAME: SIGNATURE: PAYMENT METHOD: CASH CHECK DATE:
330 Lexington Drive, Buffalo Grove, IL 60089 Phone: 847-495-7000; Toll Free: 866-353-3746 Fax: 847-495-7090 Hours 9-5PM CST www.plannedeldercare.com; info@plannedeldercare.com
□ □
TOTAL AMOUNT PAID: NUMBER: BANK NAME: ACCT NUMBER:
$
BANK ROUTING NUMBER: CREDIT CARD
□
TYPE: VISA
□
MASTERCARD
□
AMERICAN EXPRESS EXP DATE:
□
CARD NUMBER:
Outside Rep Name: _______________________________________ Outside Rep Fax: ______________________________________ Privacy Policy and Disclosure: This Policy explains what Planned Eldercare, Inc. does to keep information about you private and secure. We want you to know how we manage the information to serve you. We take a number of steps to protect the privacy of information about you. We keep information under physical, electronic or procedural controls that comply with or exceed governmental standards. We authorize our employees, agents and contractors to get information about you only when they need it to do their work for us. This Policy applies to current and former customers. This policy is effective as of December 1, 2007.