Checking Payment :: Credit Services Incorporated


	Credit Services Incorporated 304 Quincy Street Hancock, Michigan 49930 906.482.4100 Toll Free: 800.522.5346


	Credit Services Incorporated PO Box 577 Iron Mountain, Michigan 49801 906.774.5353

Claim Submission Form

If you would like to submit a claim, please use the form below.

Client Information

CSI Client Number:

Name:

Address:

City:	State:	Zip Code

Phone:	E-Mail Address:

Debtor Information

Name:

Address:

City:	State:	Zip Code

Phone:

Social Security:	Spouse Social Security:

Employer:	Spouse Employer:

Debtor Account Information

Account Number:

Original Balance:	Unpaid Balance:	Date of Service:

Medical Patient Information (optional)

Name:

Date of Birth:

Social Security Number:

Date of Service:	Physician:

Insurance Filed?	Date Insurance Paid:	Date of Last Payment:

Additional Information

Verification

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