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Financial Assistance Authorization Form
If your organization is providing financial assistance for a client, please complete this form. If you have any questions please contact:
accounting@vidaclinic.org
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* Indicates required question
Email
*
Your email
Name of person completing this form
*
Your answer
Title / Position of person completing this form
*
For example: Teacher, Counselor, Nurse, Psychiatrist, Therapist, Case Manager, etc...
Your answer
Phone Number of person completing this form
*
Your answer
Name of organization that is providing financial assistance.
*
Your answer
Approved Client First & Last Name
*
Your answer
Approved Client Date of Birth
*
Your answer
Name of person authorizing financial assistance
*
Your answer
Please describe in detail the financial assistance you are providing for this client such as number of visits, dollar amount, session type, limitations etc.
*
Your answer
Financial Assistance Authorization EFFECTIVE Date
*
MM
/
DD
/
YYYY
Financial Assistance Authorization EXPIRATION Date
MM
/
DD
/
YYYY
By my Digital Signature below I attest that I am an authorized representative to approve this financial assistance. (write your first and last name below)
*
Your answer
A copy of your responses will be emailed to the address you provided.
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