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Provide or Update Additional Information
What information are you updating or adding?
(Required)
Update Address/Name/Phone Number
Provide Insurance Information
I Have an Attorney
I was granted Financial Assistance
Name of Primary Insurance Company
Subscriber Name
ID# and Group#
Employer
Subscriber's Social Security Number
Dates of Coverage
Upload a copy of your Financial Assistance Approval Letter
(Required)
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 20 MB, Max. files: 4.
Upload a copy of your Insurance Card (Front and Back)
(Required)
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 20 MB, Max. files: 4.
Do you have secondary Insurance
Yes
No
Name of Secondary Insurance Company
Subscriber Name
Subscriber's Social Security Number
ID# and Group#
Employer
Dates of Coverage
Upload a copy of your Secondary Insurance Card (Front and Back)
(Required)
Drop files here or
Select files
Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 20 MB, Max. files: 4.
Name of Attorney
Phone Number
Reason for representation
Include any other important details here
ARG Account number or reference number (if known):
Describe the information you are updated or adding
Please note what information you are updating specifically. If any of the information required on the rest of this form is different than previously used on your account, please provide the original information in this area. This will ensure we can best match your account information and help take care of these updates for you quickly.
Please enter your full name
(Required)
First
Middle Initial
Last
Email
(Required)
Enter Email
Confirm Email
Phone
Type of phone:
Home
Work
Cell
Other
Additional Phone Number
Type of phone:
Home
Work
Cell
Other
Is the information provided here for yourself?
(Required)
Yes
No
Please enter your full name
(Required)
First
Middle Initial
Last
If no, are you a...
(Required)
Spouse
Legal Guardian
Legal Representative
Other
Describe "Other":
(Required)
Billing Address:
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Enter additional address (if any):
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
You may include any other details that could be important here.
By clicking "Submit," I acknowledge that Asset Recovery Group, Inc. (a collection agency) may use the information obtained here for the purpose of collecting a debt and that Asset Recovery Group, Inc. may contact me via email.
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Phone
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