HEALTHCARE CASH FLOW FINANCING APPLICATION

Transcription

1 HEALTHCARE CASH FLOW FINANCING APPLICATION Upon completion of this application, please sign and remit via facsimile to or the application to Date: Total Maximum Facility Amount Requested: How did you hear about us? Basic Company or Practice Information Company or Practice Name: (called the Applicant below) Contact Person: Title: Telephone: E mail Address: Facsimile: Federal Tax ID Number: Date Business Started: Date Present Management Started: Corporation Type: Partnership: Proprietorship: Date of Incorporation: County: State: Services Offered by Your Company: Area of Operation: Purpose of Financial Facility Sought: Applicant Ownership (attach a separate sheet if necessary) NAME ADDRESS CITY, STATE ZIP TELEPHONE SOCIAL SECURITY # TITLE PCT. OWNERSHIP NAME SOCIAL SECURITY # TITLE (IF APPLICABLE) PCT. OWNERSHIP (IF APPLICABLE) PRINCIPAL #1 PRINCIPAL #2 SPOUSE CHECK IF NONE SPOUSE CHECK IF NONE Applicant Business Banking Information Bank name: Account #: Contact phone: Bank name: Account #: Contact phone: City/State: Contact name: City/State: Contact name: 1 HEALTHCARE FINANCING APPLICATION GCI Application Form:892805_3

2 Applicant Borrowing Information Current A pplicant Borrowing Relationships, attach additional borrowing relationships on separate sheet LENDER NAME TELEPHONE CONTACT TYPE OF LOAN BALANCE LINE AMT. LENDER 1 LENDER 2 Collateral for borrowing relationships listed above: Receivables Inventory Equipment Other Assets: (Specify): Other Applicant Information (Please attach a detailed explanation of any Yes answer below Required) Any current/pending tax problems: Yes No Any current/pending union problems: Yes No Has the Applicant or any of its principals ever been part to an action commenced under the US Bankruptcy Code or any other insolvency proceeding? Yes No Has the Applicant or any of its principals ever defaulted or reached compromise settlement on a loan obligation? Yes No Is there any current/threatened litigation against the Applicant or any of its principals? Yes No Have any of the Applicant s principals ever been convicted of a felony of any sort or a misdemeanor of financial or fraudulent nature? Yes No PROFESSIONAL ADVISORS ATTORNEY ACCOUNTANT Firm Name Telephone City/State Contact Financial Statements Gross Profit Margin: Net Profit Margin: Estimated Applicant Net Worth: Bad debt write-off prior year: Estimated bad debt write-off this year: On what basis are financial statements prepared? Cash %Completion Average Annual Gross Revenue of Applicant: On what level of assurance are financial statements prepared? Compilation Review Audit 2 HEALTHCARE FINANCING APPLICATION GCI Application Form:892805_3

3 Does Applicant prepare any of the below internal reports? Monthly balance sheet Monthly income statement Monthly A/R and A/Paging Accounts Receivable Information Aging 1 30 Days Days Days 91+ Days Retention TOTAL Invoice Size Average: Low: High: # Invoices Monthly: #Active Customers/Patients: #Government Customers: #Commercial Customers: Sales: Monthly: This Year: Last Year: Next Year: Billing Terms: Invoice Terms: Prompt Pay Discounts: Rate of discounts: Signed Agreements with Customers/Patients? Yes No Do you sell to anyone to whom you owe money (i.e. supplier)? Applicant s Most Important Contracts (List Top 5 Balances with Full Addresses) CUSTOMER NAME CITY, STATE ZIP PHONE (NOT TOLL BALANCE 3 HEALTHCARE FINANCING APPLICATION GCI Application Form:892805_3

4 Applicant s Top 10 Sources of Payment for Healthcare Services Provided by Name of Paying Insurance Company or Governmental Payer NAME OF PAYER CITY, STATE PHONE AND CONTACT INFO APPROXIMATE ANNUAL PAYMENTS RECEIVED FROM SUCH PAYER AVERAGE ANNUAL DOLLAR AMOUNT OF INVOICES OR CLAIMS REJECTED BY SUCH PAYER Names of All Billing Service Providers in Applicant Practice Group (List Additional Providers Separately) NAME PROFESSIONAL TITLE M.D., PSYCHIATRIST, PSYCHOLOGIST OR OTHER? 4 HEALTHCARE FINANCING APPLICATION GCI Application Form:892805_3

5 Please describe in a short paragraph how the Applicant s practice is organized, the governing documents or contracts controlling practice organization, and the identity of the party or parties owning the legal and economic rights to receive payment for such healthcare services billed: Please describe in a short paragraph below the nature of the healthcare or mental healthcare services provided by Applicant s practice or practice group: 5 HEALTHCARE FINANCING APPLICATION GCI Application Form:892805_3

6 The undersigned acknowledges that this application does not bind the Applicant to sell assets, or Growth Capital International, LLC ( GCI ) and/or its assigns to buy assets. I, the undersigned, certify that all the foregoing statements and attached exhibits are true and accurate and that I have authority to speak for the Applicant and sign this document on behalf of the Applicant. Although the potential relationship between GCI and Applicant would not be a creditor-borrower or lending relationship, the undersigned nevertheless authorizes GCI and/or its assigns and agents, to undertake a credit review of the Applicant and does hereby give GCI and its assigns and agents permission to access the credit records of the Applicant and undersigned and to contact all financial and trade references and individuals and businesses for the purpose of receiving credit information and investigating and verifying the Applicant s credit history, and hereby authorizes such references, individuals and businesses to release information concerning the Applicant to GCI and/or its assigns or agents. (Person completing application) Signature: Title: Date: 6 HEALTHCARE FINANCING APPLICATION GCI Application Form:892805_3