In order for us the evaluate the purchase of your personal injury receivables, please fill out the form below and a representative from our funding department will contact you within 24 hours. This service is not available in all states.

Name of Doctors Office*
Contact Name*
Who we would contact to discuss the receivables transaction
Email*
Address*
City*
State*
Zip Code*
Phone*
Fax
How Much is the Portfolio*
List Attorneys Associated with the recievables you are trying to sell*
Do you have LOP's or a Medical Lien on all the receivables?*
*Letters of protection
Comments

Purchase your Receivables