MANAGEMENT KONCEPTS, INC.

COLLECTION AGENCY AND MEDICAL BILLING SERVICES

CLIENT ONLINE PLACEMENT FORM

Client Name:		Date (YY/MM/DD):
Client E-Mail:		Your name:


Debtor info: 

Check box if this is this a minor?YES

Amount Placed:		Debtor Acct #:
Debtor Last Name:
First Name:		M.I.:
Address:
City:		State:
Zip:
Place of employment:		Tx Driver Lic #:
Debtor home phone:		Work Phone:
Debtor/Patient SS #:		NO DASHES!
Date of Service (yy/mm/dd):		Date of Last Pay (YY/MM/DD):
Guarantor / Spouse /2nd Name:		Guarantor Phone:
Guarantor SS#:		NO DASHES!
Reference1 Name:		Reference1 Phone:
Reference2 Name:		Reference2 Phone:
Reference3 Name:		Reference3 Phone:


Comments:

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