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Contact Name:
Company Name:
Medical Specialty:
Street Address:
City: State: ZIP Code:
Phone: Fax:
Best Time to Call: Mornings Afternoons Evenings Weekends Email Address:
Length of Time in Business: Number of Locations:
Description of Healthcare Services or Medical Products Provided to Patients:
What is the General Profile of Your Patients:
What is the Current Balance of Your Medical Liens Portfolio:
Approximately How Many Cases Does it Represent:
What is the Volume of Medical Liens per Month:
What is the Average Amount of Each Medical Lien:
Any Additional Comments or Information :
