Commonwealth Financial Solutions, Inc.

Collection Placement Form

Placed in Collections by: *

Today's Date *

Account / Reference #

Debtor's (Guarantor) Full Name

Additional Name(s)

Address

Street Address

City

State

Country

Postal Code

Social Security Number and/or Driver's License Number

Date of birth

Phone *

Total Balance Owed

Litigation Approval?

Yes - Proceed with litigation if necessary

No - Do not pursue litigation

CFS Discretion - Use your professional judgment

Only if balance exceeds certain amount (specify below)

Upload invoices, statements, contract or other documentation

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF ( max 25 Files )

Additional Notes

HIPAA Acknowledgment *

I confirm that I have the authority to submit this account for collections and that all information provided is accurate. I understand that any payments received directly by our office after an account has been placed must be reported to CFS, and that collection fees will apply to those payments.

BAA Acknowledgment *

By submitting this form, the undersigned authorized representative of the above-named covered entity ("Client") acknowledges and agrees that Commonwealth Financial Solutions, Inc. ("Business Associate") will receive and handle Protected Health Information (PHI) solely for the purpose of debt collection services. Both parties agree to comply with all applicable requirements of the Health Insurance Portability and Accountability Act (HIPAA) and its implementing regulations. Client confirms they are authorized to disclose this PHI for payment collection purposes as permitted under 45 CFR §164.506(c)(4). This submission constitutes electronic acknowledgment of a Business Associate Agreement on file or agreement to enter into one prior to the transfer of any PHI.

Commonwealth Financial Solutions, Inc.

📞 540-373-6441 | ✉️ [email protected] | 🌐 cfscollect.com

Professional Debt Collection Agency | FDCPA Compliant | HIPAA Compliant