Place a Collection Account Online
Place a Collection Account via Mail or Fax
 

 

 

 

Thank you for your business.  Please fill in the information below and click on Submit.  We will promptly service your account.

OUR SERVICE DOESN'T COST -- 
IT PAYS!

 Please send our Check to:

Name:
Address:
City:
State:
Zip:
By:
(Name of Authorized Representative)
Date:
Phone:
Email:

Debtor Information

Debtor First Name:    Initial 
Debtor Last Name:
Address:
City:
State:
Zip:
Was Mail Returned?  Yes   No
Debtor Home Phone:
Debtor Work Phone: Ext:
Debtor Employer:
Debtor Employer Address:
Debtor Social Security Number:
Date of Birth:
Marital Status:
Bank Account Name:
Spouse's Name:
Spouse's Work Phone #: Ext.
Spouse's Employer:
Spouse's Employer's Address
Spouse's Social Security Number
Date of Birth:

Patient Information
(If Patient is the same as Guarantor, skip to Account Information)
Patient First Name:    Initial 
Patient Last Name:
Patient's Social Security Number
Date of Birth:
Relationship to Above:
Account Number   

Account Information
Date of Last Charge:
Date of Last Payment:
Principal Amount Due:

Miscellaneous Information
Is Guarantor a Home Owner?: Yes   No
If yes, location. 
Nearest Relative:
Is this the insurance balance? Yes   No
If not, Insurance Company Name:
Was the account: Self Pay   Workers Comp 
MVA   Liability Case 
Comments: