Hotel Pharmacy Nursing Home/Assisted Living Patient Charge Account Application
Patient Name:  ____________________________________	Social Security #:  _________________________
Patient Name:  _________________________________	Social Security #:  _________________________
Patient Phone: _________________________
Person Responsible for payment of account: ______________________________________
Social Security #: _____________________________
Address: ____________________________________________________________
Address: ____________________________________________________________
Responsible Party Home Phone: _____________________
Responsible Party Place of Employment:
_______________________________________	Phone: ____________
Address: ____________________________________
Responsible Party Credit References: (Name, address, phone, & account #)
1. _________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
Bank Information:
Name: ___________________________________________________________________
Address & Phone: _________________________________________________________
Account Type & Number: ___________________________________________________
Personal References: (Name, address, phone)
1. _________________________________________________________________________
2. _________________________________________________________________________
I give my permission for Hotel Pharmacy to receive credit information from the sources listed above, and to verify employment. I understand that my bill will be due upon receipt, and that 1 ½% interest per month (18% per year) will be charged on any balance 30 days past due, with a minimum charge of $.50, and I agree to pay all finance charges added to an overdue acount. Charge privileges will be suspended on any account with a 60-day or more past due balance, or at any other time at the discretion of Hotel Pharmacy employees.
Patient Signature: ____________________________________
Responsible Party Signature: ___________________________________
Date: ___________________