Use the following form to place an
individual account with us for collection. To
place a commercial account for collection,
click
here.
Patient/Debtor Full Name:
Patient/Debtor Date of Birth:
Patient/Debtor Soc. Sec. No.:
Responsible Party Name (if different):
Relationship:
Street Address:
City/State/Zip:
Phone No.:
Responsible Party Employer:
Responsible Party Soc. Sec. No.:
Amount Due:
Date of Last Charge:
Date Last Paid:
Mail Returned?
Additional Comments:
IMPORTANT!
PLEASE READ BEFORE SUBMITTING!
By
submitting this information to Med-Rev Recoveries, Inc., you acknowledge
and agree to the terms and conditions that require you to report all
payments, bankruptcy notices, and any communications from the debtor
directly to Med-Rev Recoveries, Inc. upon receipt or your knowledge of
their existence. You agree to immediately stop all collection efforts
on your part, and to provide copies of any paperwork that will verify
the debt, as requested by Med-Rev Recoveries, Inc. You agree to pay any and
all commissions owed to Med-Rev Recoveries, Inc. if (1) we directly collect
any monies due to you by the debtor on this account, (2) find that the
account was previously paid by the debtor, (3) withdraw the account
after demand for payment has been made, or (4) receive any monies
directly from the debtor. A faxed or E-mail signature will be
accepted to be the same as the original signature by both parties.
NO COLLECTION - NO CHARGE.
CLIENT INFORMATION
Date:
Your Company Name:
Your Company Address:
Your Company City/State/Zip:
Contact Person:
Telephone Number:
Email Address:
Please fax or mail
copies of invoices or contracts to:
FAX 315.488.4592
PO Box 280
Syracuse, New York 13209
