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? NoYes
If yes please attach a copy of the contract.

Responsible party: Your account #:
First Name: Last Name:
Business?: NoYes
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