A Professional Collection Agency
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(877) 226-0777
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The sooner you place your delinquent accounts with ABM, the greater chance we can get your money back.
Get money that is
owed to you.
Client Information:
Client Name:
Client Contact Address:
Client Telephone:
Patient Information:
Patient's Name:
Chart Number:
Minor Under 18
Responsible Party:
Home Telephone:
Cell Number:
Address:
Apt / Suite:
City:
State:
Zip Code:
Employer Name:
Work Telephone:
Employer Address:
Social Security #:
Date of Birth:
Emergency / Relative:
Emergency Telephone:
Insurance Provider:
Policy Number:
Balance Owed:
Last Date of Service:
Additional Information:
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Healthcare Placement Form, Dental-Medical...
Please Note: You must currently be a client of ABM Collection in order to fill out this form. If you would like to become a client please call us at (847) 970-6000.
Please Note: You must currently be a client of ABM Collection in order to fill out this form. If you would like to become a client please call us at (847) 970-6000.
New Address! 1819 Dot St., #4A, McHenry, IL 60050
