Debtor Information

 

            We ask that you include the following information on all accounts placed with our agency.

1.     Responsible Party/ Guarantor….(If guarantor is married, Please provide the following information on spouse as well.)

  • Address
  • Phone Number
  • Social Security Number
  • Employer Name

2.     Patient Name   (If patient is a spouse (or a child nearing 18 years old) this information is particularly important.)

  • Address
  • Phone Number
  • Social Security Number
  • Employer Name

3.     Balance Due

4.     Date of Last Service

5.     Itemized Statements

6.     Relatives-Emergency Contacts

  • Names, addresses or phone numbers that you may have from a patient history.

7.     Legal Information

  • If an attorney has been involved in any way with the account please let us know.  We also ask that you notify our office of any bankruptcy information.

8.     Financial Contracts

  • Our office will request any agreements or contracts when needed.  These documents are usually necessary only when the account is under legal consideration.

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