Medical Liens 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 portfolio? Approximately how many cases does it represent? What is the volume of Medical Liens per month? What is the average amount of each Medical Lien? Any Additional Comments or Information?

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