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Medical Account Form

Patient - Surname First
Age
Responsible Party
Relationship
Last Known Address
City
State
ZIP
Mail Returned Yes
No
Your Account
Ref. #
Previous Address
Tel. #
S.S. #
Dr. Lic. #
D.O.B.
Employment of Responsible Party
Address
Tel. #
Names of Relatives
and References
Address of Same
Tel. #
Name of
Insurance Co.
Pol. #
Tel. #
Amount Owing
Principal
$
Int. $
Total $
Date of Last
Transaction
Date Interest
Figured to
% Rate %

The above claims are justly due and are hereby assigned to you with authority to collect, sue, discharge and to endorse checks or money orders sent to you in our behalf. You will advance court costs or collect them from those listed above. You will send us 100% of principal collected minus any commissions due you. The rate is contingent upon collection -- no collection, no charge. You retain any surplus over face value of the account.

A discovery fee of 1/2 the commission rate will apply for locating payments and for effecting merchandise or equipment returns for settlement of accounts. Western Capital International ., Inc. will not be obligated to file suit on any claim and is not liable for claims becoming barred by the Statute of Limitations. A faxed or E-mail signature will be accepted to be the same as the original signature by both parties.

We and Western Capital International ., Inc. by virtue of us assigning and them accepting our accounts for collection, agree to hold each other harmless from any and all damages, attorneys fees and costs for any errors, negligence or wrongful acts committed by either involving an account assigned to them by us. WE AUTHORIZE YOU TO ENDORSE CHECKS AND MONEY ORDERS.

Date
Your Company Name
Your Business Address
City
State
ZIP
Telephone
Fax
Signed by
E-Mail


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