PROVIDER APPLICATION FOR MEDICAL LIEN PORTFOLIO PURCHASE

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1 G CA HNOW F OYOUM D CA N C F d g f d gp fm d ( OP ) g p y w U W b p d gf g f p f f 10y W yb q dbyp b mp y d b p b Y dw gf y d k f py m by gy m d f d g p yf mp Wp d d w p ya p f f mub dm d p d W pf p z p g m p y d g gb OMOF HADVAN AG OFWO K NG D C YW HCA F UND NG C mmd wf md p d m k f m g y m d gf y m p df d g p : O m md d g p G g wf p p p gd P f p d wb y f : A py p F p P M g m m my m my mg g d ( M C ) FYOUB U N B A D N HU CA F OAF CON U A ONW HAN XP

2 POVD APPCAON FO MDCA N POFOO PUCHA C fm Y Nm: Cmpy Nm: Add: Cy: Zp D Nmb: P Nmb: F Nmb: m Add: Md py: Ow Nm: B fm Nmb f B : g f m B: P Pd Bf Dp f Md Pd H Pdd P: P Pd G Pf f Y P: C B f Y Md Pf: Appm Nmb f C p: Vm f Md p M: A f fw p b dd w? D fm y dg db f d (dg fm p fmy mmb)? f y, w wm d w m: Hw dd y b C Fdg? C Fdg 12 46, 6, Nw Yk, NY F

3 PAN APPCAON FO MDCA FUNDNG d fwg pg b mpd by p P f mpd d gd fm Y fm Nm: Add: Cy: Zp Hm P: C P Wk P m: D f B N Y Ay C fm Ay Nm: Fm Nm: Off Add: Cy: : Zp: Off P Nmb F: m: fm A y y d d y p? f y, by w mpy? A y d d y Md Pym (Md Py) P y P (PP) bf? W y d by y py f p d? f y, by w mpy? Hw my d w d y y pdg? W y d d? f y d, p d, p b : C Fdg 12 46, 6, Nw Yk, NY F

4 fm b dd d y D f dad: : Dp f dd: Dp f y fm dd: Add fm H y d y d fm w fdg mpy g y w? f y, w m? Nm f Fdg Cmpy C Fdd H y fd f Bkpy? f y, w? W bkpy dgd? f y, w? H y dy d y gy f dbd b fm d? f y, w d w kd? H y m fm wk f y? f y, w m m dd y m? g d Akwdgm By my g bw, fy my p p pp fm f d dd my p w b p f fm w b d by fdg dg my pp f md fdg mpg pp, m kg md g d fm C Fdg, ffd fdg dw g d q gdg my md d m my pd() d q g my g my y() pp f f my pp ppd, dd pym f my w b pd my bf dy my pd() py f my y m, d fd w b pd dy m f m ppd d k fdg, dd m pb f f my By my g bw, by z d d my y() d b md pd() d fm b my, dg, m, g fdg dg my pp gd: P Nm: D: N App: C Fdg d ff fdg ggd p f w md, pdg y fm f g md d N g d, ff pd md m g p f y md by C Fdg ffd fdg, p gg pp, y py g P d gy gd dy w md pd m g, d y gdg g g, qfd pf wy b f fm d gd C Fdg 12 46, 6, Nw Yk, NY F

5 POVD APPCAON FO NG POCDU MDCA FUNDNG pg b mpd by pd Pd fm Nm f Pd, Gp Fy: MgBg C Nm P : P Nmb: : F Nmb: m: B Add: Cy: : Zp: D Nmb: g Py Nm: py: Ow Nm: P fm Nm: Appb? N: - - D : fd By P pg Ay: Fm Add: Ay P Nmb: Ay F Nmb: fm b dd D f P yad: yp f Ad: Dp f : Dp f mmddppd gy d : A pd f qd f? f y, p g pd d fm? H d f ppd m b dd? C m f f ppd gy d y d fw p H pd pfmd p gy f p y, f w? B f pd bg d Pym d f p d C Fdg 12 46, 6, Nw Yk, NY F

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