Personal Injury AR Assessment

Please tell us more about your Personal Injury Accounts Receivable.

ACCOUNTS RECEIVABLE INFORMATION

What is the average age of your outstanding PI AR? *

Bills 12 months old or less
Bills more than 12 months old but less than 24 months old
Bills more than 25 months old but less than 48 months old

Have you worked with a funding company previously? *

Yes
No
Currently use one, but am still interested in discussing OPMF reimbursement rates

Prior to funding, we must obtain DOL • Bills • Records • Lien/LOP • Attorney contact info • Patient contact info • Auto insurance info • Synopsis of liability. Will you be able to provide this information? *

Yes, I have all of this information ready to submit for review
Yes, but I am missing some of the details listed above
Yes, but I am missing most of the details listed above
No, I am missing all of the details listed above
Other

Your Name *

First

Last

Mr.
Ms.

Title *

Facility Name *

Address

Address Line 1

City

State

Zip Code

Email *

Phone *

Phone Type (copy)

Office
Mobile

Personal Injury AR Assessment

ACCOUNTS RECEIVABLE INFORMATION

OTHER INFORMATION

(520) 829-6140