THIRD-PARTY PAYER FORM

First

Last

Birthdate

Address

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

Preferred Y Location

Caregiver/Guardian (if different from above)

Relationship

Caregiver/Guardian's Email

Caregiver/Guardian's Phone Number

Organization

Contact For Billing (FI, Care Manager, Broker, etc)

Email Invoice To

Rep Phone Number

Acknowledgement

To begin membership, payment must be received prior to membership or program participation.

Acknowledgement

An invoice will be emailed to the above designated payer with the option to pay for the 12-month membership in full by check or credit card, or monthly draft by credit card.

Note: Family members living in the individual’s household who would like a family-type membership will have the option to sign up at a discounted rate.