Report a Delinquent Account

File a new delinquent report:

Please provide as much information about the account as you can.

Client information: First Name (required)
Last Name (required)
Birth Date
Employer
Social Security Number
Driver's License or ID
Email Address
Cell Phone

Additional responsible party information: Full Name
Birth Date
Employer
Social Security Number
Driver's License or ID
Email Address
Cell Phone

Contact information: Home Phone
Street Address
City
State (required)
Zipcode

Additional information: Child(ren)'s First Name(s)
Amount Owed
Date Contract Began
Contract End Date

Check all that apply:
Balance due to bounced check:
Balance due to unpaid copay:
Balance due to no notice:

Notes

I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge.

Note: after a report has been submitted, you will only be able to edit the amount owed and the notes. If you leave an area blank, you will be able to add more information later. Contact us if there is a critical edit.