Medical Liens and Letters of Protection Information Form

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Consumer Receivables

Medical Liens and Letters of Protection Information Form



Contact Name

Company Name or Medical Facility Name

Medical Specialty

Street Address

City	State	Zip


Phone #	Fax #

Best time to call	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 / Letters of Protection portfolio?


How much of that portfolio is 90 days old or older?


What is the volume of Medical Liens / Letters of Protection per month?


What is the average amount of each Medical Lien / Letters of Protection?


Any Additional Comments or Information?