Russell Collection Agency, Inc. - over 30 years of experience Date below Russell Collection Agency, Inc.
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Submit an Account

Your Information
RCA/CSB Client # (if available):
Your Name* (required):
Address:
City:
State:
Zip:
Your Phone* (required):
Fax #:
Your E-mail (if available):

 

Debtor Information
Patient name:
Responsible party *(required):
Address:
City:
State:
Zip:
Phone:
Cellular Phone:
Patient's Social Security Number:
Responsible parties Social Security Number:
Responsible parties employment:
Employer's phone:
Patient's Date of Birth: Format example: 010105
Responsible party Date of Birth (if available): Format example: 010105

 

Spouse/Co-maker information
Name:
Address (if different):
City:
State:
Zip: (+4)
Phone (if different):
Social Security Number:
Date of Birth: Format example: 010105
Employment:
Employer's phone:
Is spouse/co-maker also responsible for debt? (select one)

Account information
Your account number:
Unpaid balance (*required): $
Interest: $
Date of Service (*required):
Format example: 010105
Delinquent Date:
Format example: 010105
Did insurance pay?
Type of Insurance:
Is account disputed?
Mail returned?

 

Comments/Additional Information:

(Relatives, reference, etc.)

By submitting this form, the creditor represents and warranties that it has provided all required Truth in Lending disclosures to each holder listed on this form, and obtained all necessary signatures so as to fully comply with the law.

The creditor further agrees to inform the undersigned collection agency upon its receipt of any information which would render the account information contained herein more complete, accurate, or obsolete, including but not limited to, notice of a consumer bankruptcy filing.

Thank You!


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