PHG Financial Recovery Services, LLC. - Receivables Management for Healthcare Providers

A/R Analysis

Please fill out this form, which will be sent to one of our Accounts Receivable Experts for review. After a full review is completed, someone will contact you with solutions designed specifically for your business needs. Alternatively, you can print this page - fill it out by hand - and fax it to us at (727) 217-9071

Your Name
Business Name
Address
City
State
Zip
Phone
Fax
E-mail
Type of Practice/Business
Average Invoice Size ($)
Average Time to Collect (days)
Average Monthly Billing Volume ($)
Average Monthly Collections

Accounts Receivable Breakdown
Please enter amounts in percent.

Insurance	Medicare	Medicaid	HMO/PPO	Blue Cross	Workers Comp	Self Pay	Other

A current Aged Trial Balance (in $) of your Accounts Receivable in 30-day increments broken out by payer type
(i.e. Medicaid, Medicare, Commercial Insurance, etc.), in the form as follows:

Payer Class	Days Outstanding							Write Offs
Payer Class	0-30	31-60	61-90	91-120	121-150	151-180	180+	2003	2004
Medicare
Medicaid
Commercial Ins.
HMO/PPO
Blue Cross
Workers Comp.
Self Pay
Other

Web Design by DevelopedWeb.com