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Health Professionals Recovery Specialists
Office(225) 273-7770 Toll Free 1-877-265-7770 Fax (225)273-7779


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Medical Facility

Facility Name:

Contact Person:

Phone:

Fax:

email:


Note: Please fill out the information requested below. We realize the numbers are going to be estimates only.

ESTIMATED

INITIAL PLACEMENT INFORMATION.

Please fill out your estimate of the current accounts that would be placed with HPRS.

  # of Accounts $ Amount
45 Days
60 Days
90 Days
120 + Days

 

ESTIMATED - ACCOUNTS TO BE PLACED EACH MONTH

Please fill out the following information about accounts that would be placed with HPRS at the end of each month.


    1. Estimated age of the accounts would be days.

    2. Estimated # of accounts turned over each month would be .

    3. Estimated total dollar value of the accounts would be $.