Medical Factoring Worksheet
Response Required Company Name
Response Required Company Address
Response Required Contact Person/Position:
Response Required Telephone Number:xxx-xxx-xxxx
Response Required Fax number:(xxx)xxx-xxxx
Response Required Email address
Response Required Type of practice/business:
Response Required Structure of Business
Response Required How long in business?
Response Required Average Monthly Billings($)
Response Required Average Monthly Collections($)
Response Required Average invoice size ($)
Response Required Average number days to collect:
Response Required Average A/R outstanding over 90 days($)
Response Required Bank Loans ($)
Response Required Loan Collateral (if any)
Accounts Receivable Breakdown by %:
Response Required Insurance
Response Required Medicare
Response Required Medicaid
Response Required HMO/PPO
Response Required Workers Comp
Response Required Self Pay
Response Required Other(Please Specify)
Thank you. We will respond to you within 24 hours, if submitted on Sat. or Sun., we will respond by Monday. Your information is secure and confidential. 
Please contact Fred Coutts with any questions at 206-281-3153 or 1-888-942-6639
Fax # 206-378-1070
Email Fred@FredCoutts.com
Web: www.FredCoutts.com
 
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