Healthcare Funding Application

Please enter the required information in the form below.

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: