HEALTH CAPITAL INVESTORS, INC.
545 Fifth Avenue - 9th Floor - New York, NY 10017
Telephone: 212-421-4040 - Facsimile: 212-421-7171
A/R Breakdown: Insurance: % HMO/PPO: %
Medicare: % Workers Comp: %
Medicaid: % Self Pay: %
Other (Specify): %
Average Invoice Size: $
(Invoice size is defined as the total dollar amount billed for a patient on a single HCFA Form or during an electronic transmission at one time)
Average Time to Collect (in days):
Average Monthly Billing Volume:$
Average Monthly Collections:$
Average Monthly Operating Expenses:$
Reason for Attaining Working Capital / Use of Proceeds:
Required Payoffs:
1.
Party
Amount
Lien Filed (yes/no)
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Your impression of the principals to date: (circle one)
Date: