What Cases Qualify?

  • Personal Injury Vehicle
  • Personal Injury Premises
  • Personal Injury Assault
  • Slip and fall
  • Malpractice
  • Negligence
  • Exposure
  • Most personal injury's due to negligence
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Online Application

Fill out our online application to see if you qualify.

Funding Main arrow Healthcare Providers arrow Healthcare Provider Application

Healthcare Provider Application
Healthcare Provider Application
Business Name
Date Business was Established
Mailing Address
required field
City
required field
State
required field
Zip Code
required field
Physical Address
City
State
Zip Code
Telephone
required field
Fax
Firm Organization Type
Tax Identification #
Is the business name the same name that attorneys are invoiced under?
If no, please list name business name here
Accounts Receivables Contact
Name
Title
Phone
Fax
Email Address
Hours
Additional Information
Are there any other d.b.as., or Fictitious Business Names used
If yes, please list here
Estimates of Attorney Accounts Receivable
First Name
Last Name
Title
Physical Address
Telephone
Fax
Are receivables currently or previously collateralized?
If yes please explain
Approximate Number of Accounts
Average monthly attorney billings in dollars
Average Invoice Amount
Average Annual Write Down
Supplement

I do hereby authorize Pre-Settlement Healthcare Funding, LLC (PSH) to complete a corporate credit check to verify any liens or judgments.? Furthermore, I understand that the application process is not an offer to finance.? A purchase agreement with terms will be presented by PSH or a vendor of PSH with terms and agreement for purchase of attorney liens.?

The undersigned is authorized to submit application for a purchase agreement requiring the assignment or sale of attorney lien or letter of protection invoices or account receivable related to personal injury clients represented by attorneys.

PSH will ?require a copy of the imaging results of each client.? In providing our firm a copy of the results and or other medical records, please make sure you are in compliance with HIPAA.? If you need a HIPAA release form please let us know.
Client Signature
Date
required field = Required
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