Once we receive the information from the web form below we will
e-mail you a Non Circumvent non Disclosure Agreement you will
need to sign and fax back to us.
The information we receive from you will be reviewed and sent to
one, or several, Finance Companies. If a Finance Company makes
the decision to consider purchasing your pharmacy receivables
they have an application that will ask more detailed questions
and you will need to submit additional documentation such as:
1. Bank references
2. Contact information of your attorney and accountant.
3. Financial statements.
4. Accounts Receivable Aging Report.
5. Tax returns.
6. Articles of Incorporation or Partnership Agreement.
7. Other documentation to satisfy the comfort level of the
finance company functions of your pharmacy. Understand that
financing of any type can’t happen without taking the time to
satisfy the funder’s requests for information. Each finance
company will have their own; applications, documentation
requests, and each will check your credit. Your quick response
will facilitate the process.
Initial information for
Accounts Receivable Financing:
Owners Name:
Business Name:
Street:
City, State, Zip:
E-Mail:
Work Phone:
Work Fax:
Work E-Mail
Home Phone:
Home Fax:
Home E-Mail
Cell Phone:
Pharmacy Sales
Total yearly sales?
$
Total monthly sales?
$
Total monthly prescription sales?
$
Total monthly sales in DME or HME?
$
Total monthly government and insurance receivables (no
personal)?
$
Average number of scripts filled per month?
#
Average price of the scripts filled per month?
$
Percent of sales – Insurance.
%
Percent of sales - HMO/PPO.
%
Percent of sales - Workers Comp.
%
Percent of sales – Medicare.
%
Percent of sales – Medicaid.
%
Percent of sales - Other programs.
%
Accounts Receivable
What is the average number of billings you have in a
month?
#
What is your average monthly gross billing volume?
$
What is the average invoice size?
$
Total A/R under 90 days old?
$
Total A/R over 90 days old?
$
Average time to collect?
Days
What is the average percent of your monthly billing you
collect?
%
What is the amount of bad debt you wrote off last year?
$
How much of your A/R do you want to sell, so you get the
cash quicker?
$
Billing
Can you submit your billing electronically?
Yes:
No:
Do you use a service(s) to complete your billing?
Yes:
No:
If so please
describe:
Legal
Do you have any current bank/finance liens?
Yes:
No:
Do you have any current Federal, State, County, or City
liens?
Yes:
No:
Have you, or officers of the company, ever been
convicted of a felony?
Yes:
No:
Have you, or any officers of the company, ever been
involved in a bankruptcy?
Yes:
No:
Do you lease or own you’re the real estate of your
business location?
Lease:
Own:
Previous Factor
Have you used a factor in the past?
Yes:
No:
If so, which company?
What was your experience with them?
Are your receivables currently pledged to another factor
or as collateral for any loans?
Yes:
No:
If so, with whom?
You have read the information related to discount rates
and accounts receivable financing, so you have an
understanding of the factoring/cash flow financing
process?
Yes:
No:
When you have questions regarding pharmacy finance, valuations,
or acquisitions please contact
Washburn & Associates.
