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 Attorney Form

Attorney Questionnaire Form

Please Note That This Information Is For Case Evaluation Purposes Only, and Will Not Be Shared With Your Client.

In order for this case to be considered for funding, we require answers to the questions below. Please forward any documents requested to our office.

Attorney Questionnaire Form
Attorney Information
Attorney's First Name
Last Name
Firm Name
Address
City
State
Zip
Phone
Fax
Email
Case Information
The claim is in regards to the case which took place on or about
and for which the client has retained the above-mentioned attorney to prosecute same; all injuries are a direct result of this claim and no others.
Clients's First Name
Last Name
Social Security Number
Address
Incident Occurred In City
State
Suit Filed
Yes No
Settlement Offer (verbal or written), if any
Liability Been Admitted
Settlement Prospects
Good Fair Poor
Your Estimated Value (Dollar Value)
Type of Case
Property Damage (if applicable)
Under $4000 Over $4000
Date of Birth
Phone Number
Mediation Date
Settlement Demand, if any
Please note this information will not be revealed to anyone including your client and we understand you are not offering a guarantee or opinion as it pertains to the viability of this case.
Insurance Company
Policy Limits
Details of Case (Theory/Basis)
Extent of Injuries (Physical/Financial)
Medical Treatment Information
MRI
Yes No
Surgery
Yes No
Fractures
Yes No
Emergency Room
Yes No
Length of Hospital Stay
Still In Treatment
Yes No
Case Summary
Case on Contingency
Yes No
If yes, percentage of contingency
Medical Costs (to date)
Lost Client Income (to date)
Leins and Amounts Filed to Date Professional, Personal Loans/Services
Estimated Date of Settlement
Attachments
  1. MRI Yes/No If yes please attach copy of MRI report. If multiple MRI’s attach all reports.
  2. Medical records. Not all medical records are required, a summary will suffice.
  3. A report indicating that the injury directly relates to the subject personal injury.
  4. Please attach a detailed schedule of healthcare providers required to complete procedure.
  5. Priors, please indicate if client has disclosed any previous claims for personal injury cases, whether settled, lost, won or otherwise.
Our Services
Pre-Settlement Healthcare Funding (PSH) provides non-recourse healthcare funding for clients that suffer from personal injuries sustained via an accident or claim.

Healthcare providers are paid directly in advance or at the time of services provided. PSH will secure an attorneys lien for payment made to healthcare provider. Healthcare provider is not affected by the outcome of lawsuit or settlement. Should the client loose their case or claim for any reason, neither the client, healthcare provider nor attorney is required to repay any amounts advanced for healthcare.
Requirements
  1. Client must be represented by an attorney in a present ongoing claim or lawsuit.
  2. Healthcare needs are a direct result of injuries sustained in an accident, in which liability is clear and the defendants insurance is adequate.
  3. The attorney of record must agree to an attorney’s lien in the amount of our advance and fees.
  4. All healthcare providers must agree to a one time not to exceed payment from PSH for services rendered.
  5. Client and healthcare providers agree to hold PSH and it’s vendors harmless.
Benefits
  • Healthcare
  • Relief from stress of out of pocket medical expenses
  • Improved case value
  • No credit check
  • No monthly payments
  • No upfront cash out of pocket fees
  • Non-recourse money – should the client lose the case no repayment is necessary

Thank you for submitting your application for our review. The submittal of your application is not a guarantee of funding. By submitting your application you agree that the Pre-Settlement Healthcare Funding Group (PSH) automation process will capture and store your IP address for security purposes only. PSH in no way offers your information for sale or exchange. Should you have any questions, please feel free to call us Monday through Friday 9:00 AM - 5:00 PM EST. Our office is closed on all governmental holidays.
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