Arco Collections : Credit Card Form

Credit Card Form

By completing and submitting this form, I affirm that:

I authorize a charge to the specified credit card.
I am authorized to perform this transaction by the legal party to the debt(s)
I am authorized to perform transactions using the card information provided
I certify that the debt owed to the creditor is in my name and I am granting ARCO Collections permission to communicate with me by email if needed.

Debtor Information

Debtor Name *

Address *

City *

State *

Zip *

Employer

Employer Phone

Account# *

Creditor Owed

Cardholder Information

Name that appears on your credit card *

Address (must match credit card) *

City *

State *

Zip *

Email *

Home Phone *

Payment Information

Card Type *

Card Number *

Expiration/

Security Code *

Payment Amount (format: xxx.xx) *

Message

More information:

Testimonials

"At the Regional Medical Center at Memphis, patient satisfaction is PRIORITY ONE. ARCO has made a special effort in working with our office and patients to resolve account disputes and handle on-going patient collections in a manner consistent with industry standards.

ARCO would be an asset to any business regarding their collection needs."

Judy Briggs
Executive Director Revenue Cycle

Arco Collections : Credit Card Form

Credit Card Form

Testimonials

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