Benchmark Receivables Management

** NOTE: If you're a medical professional wishing to place a claim and have Benchmark begin the collection process, please click here.

To place a standard claim and have Benchmark begin the collection process, use one of the 3 methods below.

(1)

Download the PDF form to the right. Print it, fill it out, and fax it to:
1-888-988-0425.

Place A Claim Form

If you don't have
Adobe Reader
Get it Here

(2)

Download the PDF form to the right. Print it, fill it out, and mail it to:
Benchmark Receivables Management
2900 Delk Road
Suite 700 # 319
Marietta, Georgia 30067

(3)

Enter the information below, and click the Submit button.

Commercial Claims
For electronic transmittal of a new 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 Information (Benchmark Client)

Date (mm/dd/yy)*
Company Name*
Address 1*
Address 2*
City*
State*
Zip*
Phone Number (555-555-5555)*
Contact Name*
Email Address*

Add Interest to Debt? Yes No
Interest Rate %*

Add Collection Fees to Debt? Yes No

Debtor Information for Collection

Customer Account Number*
Company or Debtor Name*
Address*
City*
State*
Zip*
Contact Name*
Contact Title
Contact Phone (555-555-5555)*
Mobile Phone (555-555-5555)
Fax (555-555-5555)
Email Address

Personal Guarantee? Yes No

Signed Agreement? Yes No

Credit Application? Yes No

Special Notes

Balance Information

Date of Last Service/Invoice (mm/dd/yy)*
Number of Invoices (in the balance)
Description of Debt (type of service/product)*
Last Payment Date (mm/dd/yy)*
Prinicpal Amount (invoices)*
Interest Amount (if any)
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