We ask that you include the following information on all accounts placed with our agency.

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1.     Responsible Party/ Guarantor….(If guarantor is married, Please provide the following information on spouse as well.)

• Address
• Phone Number
• Social Security Number
• Employer Name

2.     Patient Name   (If patient is a spouse (or a child nearing 18 years old) this information is particularly important.)

• Address
• Phone Number
• Social Security Number
• Employer Name

3.     Balance Due

4.     Date of Last Service

5.     Itemized Statements

6.     Relatives-Emergency Contacts

• Names, addresses or phone numbers that you may have from a patient history.

7.     Legal Information

• If an attorney has been involved in any way with the account please let us know.  We also ask that you notify our office of any bankruptcy information.

8.     Financial Contracts

• Our office will request any agreements or contracts when needed.  These documents are usually necessary only when the account is under legal consideration.