ACCOUNTS RECEIVABLE FINANCING PRELIMINARY APPLICATION

 HEALTH CAPITAL INVESTORS, INC.

545 Fifth Avenue - 9th Floor - New York, NY  10017

Telephone:  212-421-4040 - Facsimile:  212-421-7171
Provider’s Name:
Type of Practice / Business:

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)  

 

Legal Name of Entity:
Address of Central Office:
Name of Contact Person:
Title:
Telephone:
Facsimile:
Address of all locations and other names used, if applicable:
Tax ID #'s: 
Details of Business and Ownership Structure:

FINANCIAL AND OPERATIONAL DATA:

1.  The latest two years of financial statements (audited, if available), most recent interim financial statement, and the latest two years of corporate tax returns.

2.  An overview of the company and a description of its management team.
3.  Desired amount of financing and proposed use of proceeds:
4.  Outstanding debt and the asset(s) it is encumbering, if any:
5.  A current Aged Trial Balance of your Accounts Receivable in 30-day increments broken out by payor type (i.e. Medicaid, Medicare, Commercial Insurance, etc.), in the form as follows:

 

Payor Class

Days Outstanding
0-30 31-60 61-90 91-120 121-150 151-180 180+
Medicare                            
Medicaid                            
Blue Cross/Shield                            
Commercial Ins.                            
HMO/PPO                            
Self-Pay                            
Workers Comp.                          
Other (Specify)                           

 

Once completed, please mail all three pages to:  Health Capital Investors, Inc. ~ 545 Fifth Avenue ~ 9th Floor ~ New York, NY  10017

Or fax to:  (212) 421-7171

 

 

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For Health Capital Internal Use Only

 

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