Provider Name
Present Address
City Sate Zip
Phone: Fax Email
Type of Facility Physician Hospital SNF Long Term Care Durable Medical Other
Structure Corporation Partnership Sole Proprietorship LLC Date Est.
License Number Federal Tax ID Number
Administrator/Owner
Chief Financial Officer
Director of Patient Accounts/Business Office
Director of Data Processing
Manager of Collections
What liens exist against the accounts receivables?
Bank No Yes Amount
IRS No Yes Amount
Other No Yes Amount
How long does Provider desire to continue selling receivables?
How much cash is requested in initial funding?
Is there current or pending litigation against Provider? Yes No
Does Provider do its own payroll? Yes No Third Party Name
Are Payroll taxes current? Yes No If not, amount delinquent
Are Federal Taxes Current? Yes No If not, amount delinquent
Has Provider ever had a Medicare offset? Yes No If yes, amount of offset
Amount of previous offset(s) remaining unpaid
Is there a Medicare offset pending? Yes No Estimated amount
Date of last cost reporting filing
What is the average number of insurance claims billed per month? Inpatient Outpatient
What is the dollar amount of insurance claims billed per month? Inpatient Outpatient
What is the average total amount billed to insurance payors per month? (complete below)
Commercial Insurance %
Medicare %
Medicaid %
HMO/PPO %
Workers Comp. %
What is the total amount unpaid insurance claims aged less than 91 days in the above financial classes?