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.