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SUBMIT NEW BUSINESS

CBM Client Information

New CBM clients please fill in all client fields. Existing CBM clients only need to fill in Client Name and Collection Type.
Client Name
Field is required!
Phone Number
Field is required!
Email
Field is required!
Client Account Number:
Field is required!
Authorized By
Field is required!
Collection Type
  • - select a option -
  • Standard Collection
  • Precollect
- select a option -
Field is required!

Debtor Information

Know Account Number?
Field is required!
Debtor Account Number
Field is required!
Account Balance
Field is required!
Date Of Service
Field is required!
Know Date of Last Payment?
Field is required!
Date Of Last Payment
Field is required!
First Name
Field is required!
Last Name
Field is required!
Name Of Responsible Party (if any)
Field is required!
Know Address of Debtor?
Field is required!
Address
Field is required!
Address 2
Field is required!
City
Field is required!
State
Field is required!
Zipcode
Field is required!
Place Of Employment
Field is required!
Know SSN of Debtor?
Field is required!
Social Security Number
Field is required!
SSN of Responsible Party (if any)
Social Security Number
Field is required!
Debtor Phone
Phone Number
Field is required!
Responsible Party Phone (if any)
Phone Number
Field is required!
Place Of Employment Phone
Field is required!
Know DOB of Debtor?
Field is required!
Date Of Birth
Field is required!
Responsible Party DOB
Field is required!

Spouse Information

First Name
Field is required!
Last Name
Field is required!
Date Of Birth
Field is required!
Social Security Number
Field is required!
Phone Number
Field is required!
Is Spouse Responsible Party?
Field is required!

Additional Information

Field is required!
Submit

New Business Listing Sheets

Print form in Microsoft Word. Fill out and fax to 989-631-0705

» New business listing sheet

HIPPA Compliance

» Business Associate Agreement