MEDICAL RECEIVABLES FINANCING

MEDICAL RECEIVABLES PROFILE / INFORMATION FORM
Provider
Contact
Title
Office Address
City
State		Zip
Phone
Fax
Email
FTEs		Monthly Payroll
Annual Revenue		Annual Expenses
Current Assets		Current Liabilities
Long Term Debt
Structure		If OTHER:
Provider Type		If OTHER:
Years in Practice/Business		Tax ID#
Medicare UPIN/Provider#
Total AR Outstanding		Average Monthly AR
Have you sold accounts previously?		Yes No
If yes, when?		If yes, price?
Estimated Breakdown of Receivables:
Private Insurance		Medicare
Medicaid		Private Patients
Workman's Comp		Personal Injury
Other		If other, describe:
Any liens against your AR?		Yes No
If YES, Please Explain
No. of Insurance Co. Billed(est)		Bad Debt Write-off(est)
Accounts Receivable Aging:
30 Days or Less		31 to 60 Days
61 to 90 Days		Over 90 Days
I am interested in AR financing		Now Within 6-12 months Please Call or Email Me