Online Claim Submission

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; 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

Capital Resource Management Inc.

Fill & submit the contact form below.

  • Financially responsible party. Cannot be a minor/child.
  • Please enter a number greater than or equal to 500.00.
  • Last date of actual services provided.
  • Date of last invoice or statement showing amount due. We must have a copy of this invoice to commence collections.
  • Last date you received a payment on this account.
  • If debt arose from services to a minor/child, enter child's name here.
  • If Co-Debtor's address, phone or employment is different, please provide it in the "Comments" box.
  • 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.
  • 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.*

  • Accepted file types: pdf, jpg, png, Max. file size: 100 MB.