201-340-6138 info@alleoncapital.com

Medical Accounts Receivable Application

    REFERRING PARTNER INFORMATION (Part 1 of 7)

    Referring Partner Company Name

    Referring Partner Full Name

    Referring Partner Phone #

    Referring Partner Email

    GENERAL INFORMATION (Part 2 of 7)

    Provider Company Name

    Provider Fictitious Name or DBA

    Street Address

    City

    State

    Zip

    Tax ID #

    License #

    Contact Person / Administrator

    Phone

    Fax

    Email

    COMPANY OWNERSHIP INFO (Part 3 of 7)

    Owner #1

    Name

    Phone

    Fax

    Email

    Owner #2

    Name

    Phone

    Fax

    Email

    Owner #3

    Name

    Phone

    Fax

    Email

    Owner #4

    Name

    Phone

    Fax

    Email

    COMPANY INFO (Part 4 of 7)

    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

    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 (Part 5 of 7)

    REVENUE BREAKDOWN PERCENTAGE (%)

    No-Fault/PIP

    Worker's Comp

    Medicare/Medicaid

    Commercial

    Lien/LOP

    Self Pay

    Other

    COMPLETED BY (Part 6 of 7)

    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.

    App Completed by

    Title

    ADDITIONAL INFO (Part 7 of 7)

    Have you spoken to an Alleon representative? If so please specify

    Additional Notes