Debt Referral - Existing SPS Client

Authority To Act

Safe Pay Smiles Existing Clients Only
Only complete this form if you are an existing Safe Pay Smiles client. Overdue patient account that you want to refer should not be part of the Safe Pay Smiles payment plans.

Commission will only be charged on successful collections.

No collection = no fees.

Commission charged tiered structure based on the age of the overdue invoice / debt.

Debt less than 90 days overdue = 12%
Debt 90 days up to 2 years overdue = 15.5%
We don't accept debt referrals older than 2 years.

If you have any questions, please contact us at:

client@collect4u.com.au

07-5658 0500
Your Practice Details
Practice Name*
Your Email*
Do you want to submit unpaid invoices for*

Single PatientMultiple Patients

Refer a Single Patient Account

Submit one or multiple invoices for a single account
Person responsible for the Patient Account

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Postcode
Mobile Number
Email
Related to Patient
Patient's Details

First NameLast Name
Upload outstanding invoice / Excel spreadsheet

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Refer Multiple Patient Accounts

Submit overdue accounts for multiple patients
You can submit copies of multiple overdue patient accounts or an Excel spreadsheet / software extract file.

If you need any help with extracting files from your currrent patient management software or accounting systems, please get in touch.

We can also provide you with an Excel template to use.

Please ensure that your referral contain the basic information for each patient below:
- Person responsible for account
- Contact details - Address, Phone & Email
- Patient Name
- Amount outstanding
- Last date of payment made / invoice date
Upload outstanding invoice / Excel spreadsheet

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Authority To Act
You hereby give us authority to act on your behalf and agree to COLLECT4U standard terms & conditions, as well as the fee schedule. Commission will only be charged on successful collections. No collection = no fees.

If you have any questions, please contact us at:

client@collect4u.com.au

07-5658 0500
Today's Date

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Authorised Signature (Use your mouse)*

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Name of Signatory
If you would like to on-charge our commission to your patient's account, we will need to review your practice standard terms & conditions. Our team will review this to ensure that you have the correct legal clause allowing us to on-charge your patient.
Upload Your Practice's Terms & Conditions

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