Medical Accounts Receivable Application

Referring Partner Company Name

Referring Partner Full Name

Referring Partner Phone #

Referring Partner Email

Provider Company Name

Provider Fictitious Name or DBA

Street Address

City

State

Zip

Tax ID #

License #

Contact Person / Administrator

Phone

Fax

Email

Owner #1

Name

Phone

Fax

Email

Owner #2

Name

Phone

Fax

Email

Owner #3

Name

Phone

Fax

Email

Owner #4

Name

Phone

Fax

Email

What type of facility is it? (Physician, MRI, Hospital, DME, etc…)

How long has the company been operating?

Please provide brief history and overview of the company

Why is the company seeking financing and/or interested in selling its receivables?

How much money are you seeking?

Has the company previously received financing or attempted to sell its receivables? If so, please provide reason and outcome.

Are there any current liens against the accounts receivable? If so, please state whether it's a bank, IRS or other lien and for how much.
NONEBANKIRSOTHER

Does the company use a 3rd party billing/collection company? If so, how long has the contract been in place?

What is the monthly gross billed amount average over the last two years? If not applicable, write N/A

What is the company's monthly operating expense?

Where does the company bank? (Chase, Wells Fargo, etc…)

How many W2 employees does the company have?

How many 1099 contractors does the company have?

How many locations does the company operate from?

How does the company generate its business, i.e. referral sources?

Has the company or any of its principals ever been involved in bankruptcy proceedings? If yes, please explain.
YESNO

Are there any claims, actions, suits or judgments current or pending against the company or its principals? If yes, please explain.
YESNO

Are there any audits by either commercial or government payors, including but not limited to general audits, desk audits, targeted probe and educate (TPE) actions and/or prepayment reviews (PPR) current, past or pending against the company or any prior companies which involved the principals? If yes, please explain.
YESNO

Have any of the principles, owners, managers, or operators of the company ever been charged or convicted of any crimes? If yes, please explain.
YESNO

Does the company do its own payroll? If not, is there a 3rd party?
YESNO

Are Payroll taxes current? If not, what's the delinquent amount?
YESNO

Are Federal taxes current? If not, what's the delinquent amount?
YESNO

Are State taxes current? If not, what's the delinquent amount?
YESNO

Please provide any additional information you deem necessary for evaluation of your request for financing / sale of receivables.

REVENUE BREAKDOWN PERCENTAGE (%)

No-Fault/PIP

Worker's Comp

Medicare/Medicaid

Commercial

Lien/LOP

Self Pay

Other

By signing below or submitting your name electronically, the Borrower, its owners/principals, or representatives filling out this application: (1) certify that all information and documents submitted in connection with this Application is true, correct and complete; and (2) authorize Alleon Capital Partners, LLC and its affiliates to receive credit reports and any other background information regarding the Borrower and its owners/principals from third parties, to verify any information provided on this application.