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Please complete our easy online application and one of our knowledgeable
Business Development Account Managers will review it and contact you
right away with a plan that will fit your company. |
If you prefer to fax this application simply fill it out and fax it to (888) 755-8521 or call (800) 346-0136 for more information. |
| Medical Practice Information | |
| Contact Name | |
| Provider (Company) Name | |
| State or Province | |
| City | |
| Phone | |
| Cell Phone | |
| Fax | |
| Corporate Structure |
|
| State of Incorporation | |
| Approximate Date of Incorporation | |
| Years in Business | |
| What type of healthcare services do you provide? | |
| Do you have any outstanding loans that have liens on your accounts receivable? if yes how much? | |
| Accounts Receivable Information: | |
| Total Receivables Outstanding (do not include Self-Pay) | |
| What is the approximate Net Realized Value (NRV) of Total Receivables Outstanding? (Approximately) | |
| Monthly average sales? (Approximately) | |
| Average number of days to collect? (Approximately) | |
| Outstanding A/Rs over 90 days? (Approximately) | |
| By what date would you like to have a your account ready to fund? | |
