Benchmark Receivables Management

For electronic transmittal of a new medical placement, simply fill in as much information as possible and click on the submit button. This will immediately transmit the debtor information to our new account placement office. You will receive a confirmation indicating successful transmission. We will contact you if additional information is needed and update you throughout the collection effort. Fields marked with * are required.

Client Practice Information (Benchmark Client)

Today's Date (mm/dd/yy)*
Practice Name*
Contact Person*
Address*
City*
State*
ZIP*
Phone Number (555-555-5555)*

Add Collection Fees to Debt? Yes No

Patient Information

Account Number*
Patient Name*
Social Security Number (please provide if available)
Date of Birth (please provide if available)
Drivers License Number
Address*
City*
State*
Zip*
Primary Phone (555-555-5555)*
Mobile Phone (555-555-5555)
Work Phone (555-555-5555)
Email Address

Someone other than patient to pay? Yes No

Guarantors Name (Responsible Party)
Relationship to Patient
Guarantors Social Security Number
Guarantors Phone

Signed Patient Agreement? Yes No

Balance Information

Delinquency Date (mm/dd/yy)
Date of Last Service (billing)*
Date of Last Payment (insurance or patient)*
Service Description (type of care)*

Insurance Submittals Completed? Yes No

Prinicpal Amount (invoices)*
Additonal Fees (if any)
Total Balance Due ($ of placement)*

Misc. Notes/ Disputes/ General Information

By clicking the Submit button above, you acknowledge that you have read and agree to Benchmark's
Terms and Conditions.

Benchmark Receivables Management

2900 Delk Rd. Ste 700 PMB 319
Marietta, Georgia 30067

Local:	770-988-0424
Toll Free:	888-988-0424
Fax:	770-988-0425