Sunday, October 22, 2017
Williams, Alexander & Associates
Collections and Debt Management Services

Debt Placement Form

You may not have all of the following information or some of it may not be current.

Required fields are in bold.


Debt Placement Form
You may not have all of the following information or some of it may not be current. Required fields are in bold.
If this is a business, please select "Yes" on the Business field

Your client name: Client Number:

Do you have a signed contract with debtor to pass along our collection fees?
If yes please attach a copy of the contract.

Responsible party: Your account #:
First Name: Last Name:
Business?:
Street:
City: State: Zip:
Phone: Other Phone:
SS#:
Date of Birth:
Debt Date:
Most recent date of last service or last payment by debtor. If check, this is the check date
Debt Amount:
Notes:

i.e., patient name if different or member name if different or any information which clarifies the service


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