Medical Receivables Client Profile

Provider Information

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)

     Payor Type                    Monthly Average Billed       Net Collectible Value        Average Days to Pay

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?