Get Started

Fill out the form below to begin the process of getting a quote for services from Capital Recovery.
Please note: Employment requests submitted through this form will not be considered.

File Number*

IF YOUR ACCOUNT IS A MEDICAL DEBT, WE HAVE PREVIOUSLY PROVIDED YOU WITH THE PROVIDER’S NAME, AMOUNT AND DATE OF SERVICE FOR THE BALANCE OWED. OUR CLIENT HAS BILLED YOUR INSURANCE AND THEY HAVE DEEMED IT THE PATIENT’S RESPONSIBILITY. TO EXPEDITE THE RESOLUTION OF THIS DEBT, PLEASE REFER TO THE BACK OF YOUR INSURANCE CARD AND THERE IS A MEMBER PORTAL WHERE YOU CAN PUT IN THE DATE OF SERVICE AND PROVIDER, AND IT WILL TELL YOU WHY THE DEBT IS OWED BY THE PATIENT VIA EXPLANATION OF BENEFITS (EOB). IF AFTER YOU HAVE REVIEWED YOUR EOB AND IT IS DETERMINED THAT THERE WAS AN ERROR IN BILLING OR THE AMOUNT OF PATIENT RESPONSIBILITY IS NOT CORRECT, PLEASE EMAIL US A COPY OF THE EOB AT CONTACT@CRCORP.NET AND WE WILL HANDLE IT ACCORDINGLY WITH OUR CLIENT. DUPLICATE REQUESTS FOR SUPPORTING DOCUMENTATION WILL NOT BE PROVIDED.
First Name*
Last Name*
Street Address*
Address Line 2
City*
State
Zip Code
Phone*
Amount Paid to Creditor*
Method of Payment
- Check
- Credit Card
- Money Order
- Cash
Date of Payment

mm/dd/yyyy
Check Number
Date of Check

mm/dd/yyyy
Date Check Cleared Bank

mm/dd/yyyy
Type of Credit Card
- Visa
- Mastercard
Last Four Digits on Credit Card

xxxx
File
Drop files here or

Accepted file types: jpg, png, pdf, jpeg, xps, Max. file size: 5 MB, Max. files: 3.
Terms & Conditions*
- I have read and accept the Terms & Conditions stated below.
Phone
This field is for validation purposes and should be left unchanged.