Healthcare Funding Application

Please enter the required information in the form below. You may also print this form and fax or mail it to us at:

Fax To:
            732.985.6879
Mail To:
            Hyland Financial Group, LLC
            228 Volkert Street
            Highland Park, NJ 08904-3119
            Attn: Healthcare Funding Department

Applicant Information

Name

Email Address

Phone Number

Fax Number

Organization

Specialty

Best Time To Contact

Postal Address

Receivable Information

Outstanding Accounts Receivables < 90 days:

Average Claim Size:

Average Monthly Billings:

Average Monthly Collections:

Average number of days to collect:

Years in practice:

Comments: