Main Page    Introduction     What We Offer     Projections & Comparisons    Placement Form

BE$T COLLECTIONS, LLC

Client Placement Form

Date: _________________________

CLIENT NAME:  ________________________

AUTHORIZED BY: _______________________________

Please fill in as much debtor information (responsible party) as possible:

Name: __________________________________________                            SS# _________________________

Address _________________________________________                         DOB _________________________

City, State, Zip ___________________________________                HOME PH# _________________________

Employer ________________________________________             WORK PH# _________________________

                                                                                                                CELL PH# _________________________

Spouse: _________________________________________                          SS# _________________________

Address _________________________________________                         DOB _________________________

City, State, Zip ___________________________________                HOME PH# _________________________

Employer ________________________________________             WORK PH# _________________________

                                                                                                                CELL PH# _________________________

Relative or other contact ___________________________________            Phone _________________________

Relative or other contact ___________________________________            Phone _________________________

Please fill in ALL account information:

Last Date of Service __________________________                              Amount Due $ _____________________*

Patient or Customer Name _________________________________        Your File # ______________________

Relationship to debtor (Circle one):      Self      Spouse     Child      Pet     Customer

Description of Services and or Comments _________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

 

Please attach an itemized list of charges and any type of application or registration form your patient or client may have filled out.

*If you have a signed consent agreement for collection and/or attorney fees, please also attach.

We greatly appreciate your business!

Main Page    Introduction     What We Offer     Projections & Comparisons    Placement Form