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