Collection Accounts SubmissiontoResults! Dental Collection Services, LLC

Collection Accounts Submission

Results! Dental Collection Services, LLC

HIPAA Compliant Case Intake Form

1810 Erie Blvd Syracuse, NY 13210

800-652-3431

Please call us if you have any questions.

Please be aware

If this form is not filled out accurately and the required documents are not attached with the account submission, we will reject the account.

Also, once the account is submitted to us and we accept it, per our contractual agreement, we do not remove the account from our process and you can not pull the account especially prior to the credit bureau reporting.

Please ensure that you review EXACTLY the amount that needs to be recovered and you are submitting to us with this form. We DO NOT alter the balance in any way once the account is submitted and accepted.

In the event the patients contact your office to pay the balance, please make sure that you direct the patients to pay the balance on our website or to call us to settle the balance to avoid further actions by our office. If there is any delay in your reporting of balance paid, you are risking further legal actions by our office against the patient. The ONLY way to stop our process is with a patient's payment of the debt. This process provides highest RESULTS! therefore the name Results! Dental Collections Services, LLC

Please follow the easy steps to submit your accounts

Screenshot/save the patient's demographics in the dental software (submit this)

Export/save the financial agreement (submit this)

Add Results! collection fee-If you can add our service fee to be paid by patient, add our fee to the ledger

Export/screenshot the ledger going back to $0 balance (submit this)

Adjust the account to $0-writing off the entire debt balance

Fill out this form

Attach the documents from steps 1,2,4

Your Advocate and On Your Side Always,

Your Colleague

Dr. Dorothy Kassab

Date Submitted*

Account #

Patient's First Name*

Patient's Last Name*

Birth Date*

Guarantor First and Last Name*

Patient's Street Address*

Patient's City, State, Zip*

Patient's Email*

Patient's Phone Number*

State*

Please enter the state that the patient resides in, compliance requires that the follow that state's laws and regulations.

Guarantor First and Last Name *

Client*

Provider's First and Last Name*

Provider's Street Address*

Provider's Address City, State, Zip*

Provider's Phone Number*

Provider's Email*

Use last payment date*

$ Balance on the Ledger*

prior to adding the collection management fee

CHECK BOX!!! ICheck the box if your financial agreeemnt allows to charge the patient collection fees.

If your financial agreement states that you are able to add the debt collection management fee to the ledger balance, please check the box. Our system will automatically add the 45% management fee to the ledger balance for you.

make sure that you also add the collection fee to the ledger balance, OTHERWISE we will remove the collection fee form the ledger balance that we collect.
write off the entire amount on the ledger to $0

SUBMIT the following supporting documents

Account ledger supporting the debt
Signed Financial Agreement (includes the terms of billing for our debt management Results's fee)
Patient demographics (screenshot from dental software)
Anything else that supports the debt is valid ex: consents

Check the Box below if the signed financial agreement allows to charge the patient the debt management fee.

Please upload the necessary documents

Drag and drop files here or

Submitted by First & Last Name/Position

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