Account Listing Form

Account Listing Form

CERTIFIED SERVICES, INC.
Your Firm Name*
Phone Number*

Area CodePhone Number
Fax Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date*

MonthDayYear
Date
Contact Person*
E-mail*
Items needed:

Listing FormsReturn EnvelopesWould like to discuss policies, practices, techniques or collection problems with representative
HOW TO GET STARTED
1. Download fill out listing form with as much pertinent information as possible. Feel free to send us your own printout or itemized statement if it would be easier. Be sure to include the name of your firm.
2. Mail, fax or email the listing form to us.
3. We will send you an acknowledgement giving a full accounting of these newly listed accounts.
4. Please call us immediately if a payment is made to your office on an account listed with us for collection. Unreported payments may cause a multitude of problems for both of us.
5. You will receive a statement for any month during which financial activity has occured on your accounts.
6. Progress reports will be rendered on request.
Responsible Party*

First NameLast Name
Spouse

First NameLast Name
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*

Area CodePhone Number
His Employer*
His Social Security Number*
His DOB*

MonthDayYear
Date
His Employer Phone

Area CodePhone Number
Her Employer*
Her Social Security Number*
Her DOB*

MonthDayYear
Date
Her Employer Phone

Area CodePhone Number
Responsible Party Cell*

Area CodePhone Number
Your Account Number*
Date of last charge:
Date of last payment:
Date delinquent:
Amount due:
Should be Empty: