Medical Accounts Receivable Financing Application

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MEDICAL ACCOUNTS RECEIVABLE FINANCING APPLICATION

Please complete the application below. Upon submission, we will contact you within 48 hours with a decision. Thank you for using our on-line system and we look forward to helping you meet your financing needs. All applications submitted are held in strict confidence.

Seller Name
Company Name
Address
City
State		Zip Code
Telephone
Fax
Email

1. Have you sold Medical Accounts Receivables in the past?
Yes
No

If yes, list previous buyers and price paid.

2. Indicate the total dollar value of receivables currently outstanding. $

3. Indicate the average dollar volume of receivables available on a monthly basis. $

4. Indicate the estimated breakdown of your medical accounts receivables:
% Private Insurance
% Private Patients
% Workers Compensation
% Medicare
% Medicaid
% Personal Injury
% Other

5. Estimated number of insurance companies billed:

6. Estimated dollar amount of bad debt write-off: $

7. Estimated percentage of accounts receivable aging:
% 30 days or less
% 31 to 60 days
% 61 to 90 days
% 91 to 120 days
% Over 120 days

8. Indicate the number of accounts receivables for which judgments or liens have been filed:

To email your application to our processing center, depress the "Submit" button.