Collection Authorisation Form

Collection Authorisation Form for the United States

Collection Authorisation Form Template for United States

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"I need a Collection Authorization Form for my medical practice that includes recurring payment authorization and HIPAA compliance provisions, to be used for collecting outstanding patient balances starting January 2025."

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What is a Collection Authorisation Form?

The Collection Authorization Form is a crucial document used in the United States when a creditor needs formal permission to collect a debt or assign collection rights to a third party. This document is essential for compliance with the Fair Debt Collection Practices Act (FDCPA) and various state collection laws. It is typically used when initiating formal collection procedures, setting up payment plans, or engaging collection agencies. The form includes detailed information about the debt, authorized collection methods, consumer rights disclosures, and privacy notices. It serves multiple purposes: protecting the creditor's rights to collect, ensuring compliance with federal and state regulations, and informing debtors of their rights and the collection process. The document is particularly important in situations involving recurring payments, multiple debts, or when specific collection methods need to be authorized.

What sections should be included in a Collection Authorisation Form?

1. Parties: Identification of the creditor, debtor, and collection agency (if applicable), including full legal names and contact information

2. Debt Information: Details of the debt being authorized for collection, including original amount, current balance, account numbers, and date of origination

3. Authorization Statement: Clear statement of the debtor's authorization for collection activities, including specific permitted actions

4. Collection Methods: Specification of authorized collection methods (e.g., direct withdrawals, payment plans, communication channels)

5. Consumer Rights: Mandatory disclosures of consumer rights under FDCPA and applicable state laws

6. Privacy Notice: Statement regarding the handling and protection of personal information

7. Revocation Terms: Terms and process for revoking the collection authorization

8. Signature Block: Space for dated signatures of all parties and any required witness or notary details

What sections are optional to include in a Collection Authorisation Form?

1. Recurring Payment Authorization: Additional authorization for recurring automatic payments, used when setting up payment plans

2. Multiple Debt Schedule: Section for listing multiple debts under the same authorization, used when collecting various debts from the same debtor

3. Third-Party Authorization: Authorization for communication with specified third parties about the debt, used when involving authorized representatives

4. Electronic Communication Consent: Specific consent for electronic communications and documents, used when planning to communicate electronically

5. Special Payment Arrangements: Details of any special payment arrangements or settlements, used when non-standard payment terms are agreed

6. Medical Information Release: Special authorization for handling medical information, used when collecting medical debts

What schedules should be included in a Collection Authorisation Form?

1. Schedule A - Debt Details: Detailed breakdown of the debt(s) including principal, interest, fees, and payment history

2. Schedule B - Payment Plan: Details of agreed payment plan including amounts, dates, and payment methods

3. Appendix 1 - Required State Disclosures: State-specific disclosures and notices required by applicable state laws

4. Appendix 2 - Consumer Rights Summary: Detailed summary of consumer rights under FDCPA and state laws

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

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A U.S. legal form authorizing the release of vital records while ensuring compliance with federal and state privacy regulations.

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What is a Collection Authorisation Form?

What sections should be included in a Collection Authorisation Form?

What sections are optional to include in a Collection Authorisation Form?

What schedules should be included in a Collection Authorisation Form?

Authors

Alex Denne

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