Submit an Account

This form is for clients to submit accounts to collections.

If you are a consumer wanting to make a payment, please visit https://choicerecoverypayments.com/

If you are a consumer requesting information, please visit the Contact Form https://www.choicerecovery.com/contact/ or call us at (866) 300-5590.
Contact Information

Please enter your contact information below.
Firm Name*
Email*
Client Account Number*
If you don’t know your client code, please call 800-559-9277
Address*
City*
State*
Zip Code*
Phone*
Submitted By*
Debtor Information

Please include all debtor information available.
Responsible Party First Name*
Responsible Party Last Name*
Responsible Party Birth Date
If the debt is for a minor, please submit the responsible party’s DOB
Responsible Party Social Security Number
If you only know the last 4 numbers, please enter "0" for the unknown numbers
Last Known Address*
If you do not know their last address, please write "Unknown"
City
State
Zip
Email
Home Phone
Cell Phone
Work Phone
Business/Employer Name
Name of Spouse
Spouse Phone Number
Emergency Contact Name
Emergency Contact Phone
Name Debt Relates To
Account Number
Collection Amount*
Insurance Provider (if applicable)
Date of Last Service*
Additional Information
Email Receipt

Email me a copy of this form
Should be Empty:

Contact Information