Account Assignment Form
Click on the Account Assignment Form icon below and the form will open in a new window. Save the form to your computer and then open it with your PDF viewer. After entering the required information save the completed form and then send it to us via (1) email (email@example.com) or (2) fax (516) 430-5015 or (3) by clicking on the Upload Files and Documents icon below for direct file upload to our secure server.
After submitting your Account Assignment Form(s), all supporting documents for the accounts being assigned should be sent in one of three ways: (1) via email (firstname.lastname@example.org); (2) via fax (516) 430-5015; or (3) by clicking on the Upload Files and Documents icon below for direct file upload to our secure server. Please note that direct file upload is strongly recommended for all medical debt accounts. Upon receipt, collections will be summarily commenced on the accounts submitted.
Please ensure that you forward a completed Account Assignment Form (or complete the online claim submission form) for each account you assign to us for collection. We cannot process supporting documents that are uploaded without a completed Account Assignment Form or online claim submission.