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		MEDICAL ACCOUNTS RECEIVABLE FUNDING APPLICATION Medical Accounts Receivable Funding Information Monthly Insurance Claims Billed * : Select $5,000 - 9,999 $10,000 - 29,999 $30,000 - 49,999 $50,000 - 99,999 $100000 - 499,999 $500,000 - 999,999 $1,000,000+ Approximate Collection Rate * : Select 0 - 10% 11 - 20% 21 - 30% 31 - 40% 41 - 50% 51 - 60% 61 - 70% 71 - 80% 81 - 90% 90% or higher   Type of Product or Service You Offer * : Estimated Annual Revenue * : Select $0 - 99,999 $100,000 - 500,000 $500,001 - 1,000,000 $1,000,001 - 10,000,000 $10,000,001+ Year Practice was Started* : Select 2007 2006 2005 2004 2003 2002 2001 2000 1999 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 or earlier How Did You Hear About Us? Select Google Yahoo MSN Live Other Search Engine iBank.com Broker Referral Personal Referral Principle Commercial Employee Other   Medical Associations You Belong To : Briefly describe how MAR funding can help your practice. I Accept the Terms and Conditions Contact Information First Name * : Last Name * :   Your Role * : Select Physician Pharmacist Hospital Administrator Office Manager Billing Company CPA/Consultant Other   Type of Practice : Select Group Practice Pharmacy Hospital Medical Clinic DME/HME Provider Medical Laboratory MRI/Radiology Center Nursing Home/Assisted Living Home Healthcare Provider Other Company Name : Address : City : State : Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code : Email Address * :   Primary Phone * :    Seconday Phone :   Best Time To Contact : Select Morning on Primary Afternoon on Primary Evening on Primary Morning on Secondary Afternoon on Secondary Evening on Secondary
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