$ Nutech Capital Resources $
Medical Receivables Application
Legal Name of Provider:
Street Addrs:
City: State: Zip:
Phone: Fax:
e-mail:
Contact First Name: Last Name: 
Your Title:
Administrator/Owner:
Chief Financial Officer:
Director of Patient Acct's/Bus Office
Director of Data Processing:
Manager of Collections:
Type of Facility?
Business Structure:
State No. of Owners/Partners:
License #: Tax ID #
Years in business: yrs
Are there any liens against the provider? yes no
Is there any pending litigation against the provider? yes no
Does it have a line of credit with a bank? yes no
Are Federal Taxes current? yes no, Amount delinquent: $
Are State Taxes current? yes no, Amount delinquent: $
Are Payroll Taxes current? yes no, Amount delinquent :$
Does provider do it's own Payroll? yes no,
Who?
Has the provider ever had a Medicare offset? no yes, Amt $
Are there any others unpaid or pending? no yes, Amt $
Why does the provider want to sell it's receivables?
How long does the provider desire to sell it's receivables?
How much cash is requested at initial purchase? $
For each appropriate payor below please indicate "Monthly Average Amount Billed", "Net Collectable Value in %", "Days to payment".
Commercial Insurance:$ per month % Days
Medicare: $ per month % Days
Medicaid: $ per month % Days
HMO/PPO: $ per month % Days
Workers Comp: $ per month % Days
Average number of insurance claims billed per month?
Inpatient: Outpatient:
Average dollar amount of insurance claims billed per month?
Inpatient:$ Outpatient:$
Average total amount of insurance claims billed per month?
Inpatient:$ Outpatient:$
Questions, Requests, Comments:

When completed please click on the submit button below:

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Nutech Capital Resources | P. O. Box 305, Brownsville | California | 95919 | USA
Ph: 530-675-9151 | Fax: 530-675-9152 | e-mail: Richard@NutechCapital.com

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