Straight Collection Form: Add A Record
View Historical Batches | Submit All Records

Once you have entered a pre collection payment record, it will appear listed below.
You then MUST click on the Submit or Submit All link to finalize your submissions.

* Denotes a required field.
* Responsible Party First Name:	First name of the person (debtor) being sent to collection.
* Responsible Party Last Name:	Last name of the person (debtor) being sent to collection.
Responsible Party Account #:	This is an account # which you may have assigned and use internally for this person. It is only supplied for informational purposes.
* Responsible Party Address:
* Responsible Party City:
* Responsible Party State:
* Responsible Party Zip:
Responsible Party Employment:	Place of Employment
Responsible Party Home Phone:	(xxx) xxx-xxxx
Responsible Party Work Phone:	(xxx) xxx-xxxx
Responsible Party Cell Phone:	(xxx) xxx-xxxx
Responsible Party Day of Birth:	mm/dd/yyyy
Responsible Party SSN:	xxx-xx-xxxx
* Amount Due:	$ (Numbers only! ie 102.23)
* Last Service Date:	mm/dd/yyyy
Bad Address:	Click this box for YES
Patient First Name
Patient Last Name
Patient DOB	mm/dd/yyyy
Patient SS#	xxx-xx-xxxx e.g. 123-45-6789
Spouse First Name:
Spouse Last Name:
Spouse Employment:
Spouse Work Phone:	(xxx) xxx-xxxx
Spouse Alternate and/or Cell Phone
Spouse DOB	mm/dd/yyyy
Spouse SSN:	xxx-xx-xxxx
Last Payment Date:	mm/dd/yyyy
More Info:
Please collect the accounts below. They are correct, just and unpaid. We have attached an itemized statement for each account or can provide one upon request. None of these accounts have been or are not listed with other collectors or attorneys to our knowledge. We agree to report promptly all payments made directly to us on these accounts. Pursuant to the Fair Credit Billing Act, we have indicated if any dispute exists regarding any account listed. We do understand that the fee for collection will never exceed 50%.

No records to send to Centron.

Review Historical Batches