Online Claim Submission

(Please ensure you have signed up for collection services before assigning accounts)

To submit a claim online, please complete the fields shown below. After submittiing the online claim, please ensure you send documentation identifying the debtor and substantiating the debt. This includes bills, invoices, contracts, credit application, work order(s), patient intake/financial responsibility forms, NSF check(s), drivers license and insurance cards.

Documents can be scanned and emailed to [email protected]; faxed to (516) 430-5015; or securely uploaded directly to our server using the file uploader. A link to the uploader can be found at the bottom of this page.

* = Required Field

Fill & submit the contact form below.

Debtor Last Name*

Financially responsible party. Cannot be a minor/child.
Debtor First Name & M.I.*
Debtor Date of Birth (month day, year)
Debtor's SSN
Debtor Address*
Street Address City State / Province / Region ZIP / Postal Code
Debtor's Home Phone Number
Debtor's Cell Phone Number
Debtor's Work Phone Number
Debtor's Email
Debtor's Place of Employment
Debtor's Employment Address
Street Address City State / Province / Region ZIP / Postal Code
Debtor's Account # at Your Business
Amount Due (Minimum $500)*
Please enter a number greater than or equal to 500.00.
Last Date of Service (mm/dd/yyyy)*
Last date of actual services provided.
Last Invoice Sent Date (mm/dd/yyyy)*
Date of last invoice or statement showing amount due. We must have a copy of this sent invoice to commence collections.
Date of Last Payment Received from Debtor (mm/dd/yyyy)
The most recent payment the debtor made on this account.
Date Account Became Delinquent (mm/dd/yyyy)*
Co-Debtor Name (additional responsible party)

If debt arose from services to a minor/child, enter child's name here.
Co-Debtor Date of Birth (month day, year)
Co-Debtor's SSN
If Co-Debtor's address, phone or employment is different, please provide it in the "Comments" box.
Creditor Name*

Company, Provider or individual owed the money.
Client Name*

Company or Representative submitting this claim.
Is this a court judgment?
- Yes
- No
Did the debtor keep insurance proceeds?
- Yes
- No
Insurance Company Name
Amount of insurance proceeds remitted to patient
Has this account previously been in Collections?*
- Yes
- No
Comments (additional addresses, phone no.'s, maiden name or aliases, etc.)
By submitting this form, I/we assign to C.R.M. this account for debt collection in accordance with the Terms and Conditions of Collection Services and affirmatively confirm that the individual providing this information is the lawful agent of the Creditor and can bind said Creditor for collection purposes.
Full Name of person submitting this account*
Please review your entries before clicking the Submit button, especially Date of Birth fields.
*Don't forget to send us your documents validating this debt.*
File
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
File
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
File
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
File
Accepted file types: pdf, jpg, png, Max. file size: 100 MB.
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Capital Resource Management Inc.

NOTICE: WE DO NOT COLLECT FOR T-MOBILE

Online Claim Submission

Fill & submit the contact form below.