Complete Collection Services Home Page

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Use this page to give us your Patient and Client Account information. No sensitive information is being collected on this page. Please be sure to provide your Patient Account Number and all other mandatory fields noted with two asteriks (**). Once you hit the Submit Button, follow the directions to provide the amount you want to pay on your account and your PayPal™ or Credit Card information. There is a nominal $5.00 service fee to use this service, effective January 1, 2010. This fee is reflected as "Shipping Fee" at PayPal™ checkout. You do NOT have to have a PayPal™ account to use this service if you wish to use your own credit card. You will, however, be given the opportunity to set up your own PayPal™ account at checkout or go to the

website.

BEFORE PROCEEDING, PLEASE HIT YOUR REFRESH BUTTON.
IF YOU RECEIVE AN ERROR MESSAGE, HIT YOUR BROWSER'S BACK BUTTON
AND THEN HIT REFRESH AGAIN!

** indicates mandatory fields

	Responsible Party Name **
	Patient Account Number **	*This is your Patient Account Number with Complete Collection Services, Inc.*
	Client Number
	Address Line 1 **
	Address Line 2
	City **
	State **
	Zip Code **
	Phone Number **
	Email Address **

	Special Instructions

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