Medical Accounts Receivable ApplicationPlease fill out the online application below. If you prefer a hard copy, please email us at info@goldenfinsolutions.com or call us at (949) 329-3696 . Thank you.Please enable JavaScript in your browser to complete this form.1GENERAL INFORMATION2LIST OF PRINCIPALS / SHAREHOLDERS IN COMPANY3OPPORTUNITY INFORMATION4SERVICING REVIEW5LEGAL REVIEW HAS THE COMPANY OR ANY OF ITS PRINCIPALS:GENERAL INFORMATIONCompany Legal Name *Primary Physical AddressMailing Address (if different than above)PhoneFaxFederal Tax ID NumberCompany Inception (mo/year)State of IncorporationPrimary treatment providedMRIDiagnosticPTChiroSurgicalDMEOtherPrimary transaction typeWorkers CompensationPersonal InjuryMedicaid/MedicareOtherDoes the Company currently operate under any other names? (If yes, please list)Has the Company operated under any other names in the past? (If yes, please list)Number of LocationsContact Person Name *Contact Person Title *Contact Person PhoneContact Person Email *NextLIST OF PRINCIPALS / SHAREHOLDERS IN COMPANYPrincipal/Shareholder IPrimary Physical AddressSocial Security No.Date of BirthPrincipal/Shareholder II (if applicable)Primary Physical AddressSocial Security No.Date of BirthPrincipal/Shareholder III (if applicable)Primary Physical AddressSocial Security No.Date of BirthPrincipal/Shareholder IV (if applicable)Primary Physical AddressSocial Security No.Date of BirthPrincipal/Shareholder V (if applicable)Primary Physical AddressSocial Security No.Date of BirthPreviousNextOPPORTUNITY INFORMATIONProvide brief overview of the Company’s historyPlease explain why you are seeking financing for your receivablesPlease describe the ideal outcome of this transaction for youWhat % of your business is workers’ compensation? PI? Other?Please describe the types of treatment or services you offerApproximately how much gross are you currently billing per month?Approximately how much are you collecting per month?How much total gross in receivables are currently outstanding?Estimated value of total outstanding bookAre you interested in an ongoing/monthly funding relationship?YesNoAre you currently being financed by any other company? If so, describe the termsPreviousNextSERVICING REVIEWName of Collection Company(s)Is the collection company(s) aware that you are selling your receivables? Is There a Termination Fee if we Decide to Move the A/R to another Collection Company? (If yes, how much?)What is the Current Process for Collecting on Your Receivables?How Often Are the Cases Being Status Checked to Confirm the Validity?Are There Any Encumbrances or UCCs on the Receivables? (if yes, please explain)PreviousNextLEGAL REVIEW HAS THE COMPANY OR ANY OF ITS PRINCIPALS:Been the Subject of Any Bankruptcy Proceedings (If yes, please explain)Been Questioned or Investigated by Any Law Enforcement Agencies (if yes, please explain)Is the Company or Any of its Principals Defendants in any Lawsuits? (if yes, please explain)Are There Any Claims, Actions, Suits, or Judgements Pending Against the Company? (if yes, please explain)MessageSubmit