Make a payment
Client login
Direct Pay
Submit Accounts
Toggle navigation
Home
Solutions
About
Careers
Contact
Make A Payment
Client Login
Direct Pay
Account Intake
EXISTING CLIENTS – PLEASE READ
EXISTING CLIENTS – This form is not for you. Please logon to our portal and enter your accounts. Thank you and have a great day!
NEW CLIENTS – PLEASE READ
NEW CLIENTS – By submitting your account for collection you are agreeing to the terms and conditions as set forth below. Thank you and have a great day!
Debt
Please list all parties responsible for this debt.
Is this a medical, dental, healthcare or veterinary debt?
Choose..
Yes
No
Debtor
Known Bad Address?
Co-Debtor
Account
(Enter the lowest settlement amount you will accept without us calling for your prior approval.)
Insurance Billed?
Yes
No
Explanation of Debt..
No Insurance
Deductible/Co-Insurance
Other (please enter details in Comments box)
Do you have a Personal Guarantee signed by the debtor or guarantor? If so be sure to upload a copy.
Choose..
Yes
No
Documentation
We require supporting documentation.
Examples could include:
Itemized ledger adding up to the balance
Signed financial responsibility language
Signed contracts
Screen prints
Copies of driver’s license
Any additional supporting documentation
Select one or more files to send the required documentation:
Choose file(s)..
Cancel
How will you be forwarding?
Fax
Email
Client
How did you hear about Secured Resolutions, LLC?
Select..
ACA
BBB
Client Referral
Internet Search
Other
Terms & Conditions
In submitting the above balance for collection, the following is agreed to: Secured Resolutions, LLC (SR) is authorized to commence its normal collection process action against the debtor. SR is authorized to accept payment, deposit funds collected and to select an attorney, if necessary. The handling of this debtor is governed by SR's standard fee schedule of 40%. If you grant SR permission to pursue legal action the fee schedule is 50% plus court costs. Court costs must be paid immediately. SR will not pursue legal action without my authorization. SR will not accrue interest or add fees. The amount placed will be the amount we attempt to recover. It is understood there is no guarantee SR will successfully recover any funds. It is understood you can not use any other agency to collect on this account until it is cancelled and returned to you by SR. While this account is in the collection program and a payment is collected, SR will provide Client with a monthly transaction journal listing all payment activity and any adjustments for the reporting period. All collections, if any, generated by SR through its collection process on this account will be remitted to you less SR’s collection fee. You agree to provide SR with information on all direct payments received by you for this account. Collection fees due SR on any statement to you are due and payable upon receipt of the statement. SR has the right to offset any such fees unpaid against collections made on this account or any account placed with SR by you. As further consideration for the receipt and handling and collection of account by SR, and for the services rendered to you by SR the parties agree that each party will assume its own proper responsibility in connection with any claims made by third party against you and/or SR. If the acts of the agent, servants, and employees of SR are the proximate cause of any action brought against you, SR will assume full responsibility for the defense of said action and the payment of any resulting judgment. If the acts of the agents, servants and employees relating to you are the proximate cause of any action brought against SR by a third party, you will assume full responsibility for the defense of said action and payment of any resulting judgment.
I agree to the above Terms & Conditions
Type your full name to agree to the above Terms & Conditions: