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{\title Medical Receivables Client Profile}{\author Karen Knott}{\operator George Karl}{\creatim\yr2003\mo2\dy14\hr10\min3}{\revtim\yr2003\mo2\dy14\hr10\min3}{\version2}{\edmins0}{\nofpages2}{\nofwords517}{\nofchars2950}
{\*\company Pino Training Organization}{\nofcharsws3622}{\vern16411}}\margl1627\margr1224 \ftnbj\aenddoc\ftnrestart\noxlattoyen\expshrtn\noultrlspc\dntblnsbdb\nospaceforul\hyphcaps0\horzdoc\dgmargin\dghspace120\dgvspace120\dghorigin1627\dgvorigin1440
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\tx10800\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\cgrid {\b\f1\fs26 Medical Receivables Client Profile}{\f1 
\par }\pard \nowidctlpar\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 
\par }\pard \sl360\slmult0\nowidctlpar\tldot\tx4680\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\b\f1 CCFC/Broker Information
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx6739\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Name___________________________Company_____________________________ Date_________
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx4680\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Address ___________________________________________________________________________
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx4680\tx5040\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 City__________________State________ ZIP_______Phone _______________Fax_______________}{\b\f1 
\par 
\par }\pard \sl360\slmult0\nowidctlpar\tldot\tx4680\tx5040\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\b\f1 Provider Information}{\f1 
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx4680\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Provider name______________________________________________________________________
\par }\pard \sl300\slmult0\nowidctlpar\tlul\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Present address \tab 
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx4680\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 City ____________________ County____________________ State ________ZIP________________
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx4680\tx5220\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Phone______________________________________ Fax\tab ___________________________________
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Contact name_______________________________  Title ___________________________________
\par }\pard \sl300\slmult0\nowidctlpar\tx1432\tx1702\tx3502\tx3772\tx5302\tx5482\tx6472\tx6652\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Type of facility\tab }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1 \tab 
Physician\tab }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  \tab Hospital\tab \tab \tab   }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  SNF
\par                      \tab }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1   Long-term care\tab }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  \tab Durable Medical Equipment\tab   
}{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  Other _________________
\par }\pard \sl300\slmult0\nowidctlpar\tx1432\tx1702\tx3502\tx3772\tx5482\tx5752\tx6202\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Structure\tab }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  \tab Corporation\tab }{
\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1   Partnership\tab   \tab }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  Sole Proprietorship
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 License number _____________________________ Federal Tax ID number_____________________
\par }\pard \sl300\slmult0\nowidctlpar\tlul\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Administrator/Owner\tab 
\par Chief Financial Officer\tab 
\par Director of Patient Accounts/Business Office\tab 
\par Director of Data Processing\tab 
\par Manager of Collections\tab 
\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 
\par What liens exist against the accounts receivable?
\par }\pard \sl300\slmult0\nowidctlpar\tx1522\tx2692\tx4132\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1       Bank \tab   }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  No\tab   }{\f1 {\field{\*\fldinst 
SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  Yes\tab Amount_______________________________________
\par      IRS\tab   }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  No\tab   }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  Yes\tab Amount_______________________________________
\par      Other\tab   }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  No\tab   }{\f1 {\field{\*\fldinst SYMBOL 111 \\f "Wingdings" \\s 10}{\fldrslt\f14\fs20}}}{\f1  Yes\tab Amount_______________________________________

\par }\pard \sl300\slmult0\nowidctlpar\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 
\par Why does Provider desire to sell receivables? _____________________________________________
\par How long does Provider desire to continue selling receivables?________________________________
\par How much cash is requested at initial funding?_____________________________________________
\par }\pard \sl300\slmult0\nowidctlpar\tx1432\tx1702\tx3502\tx3772\tx5482\tx5752\tx6202\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 
\par Is there current or pending litigation against the Provider?\tab 
\par }\pard \sl300\slmult0\nowidctlpar\tx2160\tldot\tx4680\tx5392\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Does Provider do its own payroll?________________ or use third party (name)?__________________
\par Are payroll taxes current?______________________ If not, amount delinquent___________________
\par Are Federal taxes current? _____________________ If not, amount delinquent___________________}{\b\f1 
\par }{\f1 Are State taxes current?\tab  If not, amount delinquent__________________________________________}{\b\f1 
\par }{\f1 Has Provider ever had a Medicare offset?___________ Amount of offset________________________
\par Amount of previous offset(s) remaining unpaid_____________________________________________}{\b\f1 
\par }{\f1 Is there a Medicare offset pending?________________ Estimated amount_______________________
\par Date of last cost reporting filing_________________________________________________________
\par 
\par }{\i\f1 Please complete other side.}{\f1 
\par What is the average number of insurance claims billed per month?
\par       Inpatient________________________________   Outpatient_______________________________
\par What is the average dollar amount of insurance claims billed per month?
\par       Inpatient________________________________   Outpatient_______________________________
\par What is the average total amount billed to insurance payors per month? (Complete below).
\par }\pard \nowidctlpar\tx2160\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\b\f1\fs18 
\par }{\b\f5\fs18 Payor type\tab     Monthly Average Billed                    Net Collectible Value       Average days to Pay}{\b\f5 
\par }{\f1 
\par }\pard \nowidctlpar\tx2332\tx5572\tx7012\tx7642\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 Commercial insurance\tab ______________________\tab ___________%\tab \tab _______________
\par Medicare\tab ______________________\tab ___________%\tab \tab _______________
\par Medicaid\tab ______________________\tab ___________%\tab \tab _______________
\par HMO/PPO\tab ______________________\tab ___________%\tab \tab _______________
\par Workers Comp\tab ______________________\tab ___________%\tab \tab _______________
\par }\pard \sl300\slmult0\nowidctlpar\tx2332\tx5572\tx7012\tx7642\tldot\tx9187\tx10800\faauto\adjustright\rin0\lin0\itap0 {\f1 
\par What is the total amount of unpaid insurance claims aged less than 91 days in the above financial classes? _________________________________}{\i\f1 
\par }{\f1\fs18 
\par 
\par }{\i\f1 Please attach a summary page from the aged trial balance.}{\f1\fs18 
\par 
\par 
\par /medical}{
\par }}