New Provider Intake Form

When your investment horizon matters

**IMPORTANT NOTE FROM PFD** – PLEASE READ

Welcome to PFD Management
Where Capital Meets Care

Thank you for considering PFD Management for your funding needs. For over a decade, we’ve helped medical providers like you unlock the value of their receivables to stabilize operations, fuel growth, and restore control over the business cycle. With over $1 billion in actively managed, expertly underwritten personal injury medical receivables and more than $300 million in direct funding deployed, we are proud to serve as a trusted capital partner to some of the most respected practices in the country.

We understand that your time is valuable—and your decisions, consequential. That’s why we encourage you to connect with our Provider Capital Advisory Group, “White Glove Accounts Division” to complete this form together. A brief, collaborative call allows us to better understand your goals and gives you a chance to understand how our process works and how we protect your interests every step of the way. To get started, please call us directly at 949-806-3026 or 888-475-4748 x702.

Before You Begin:

  1. Our goal is service. We want to understand your business, your challenges, and how we can tailor a solution that works for you, not just on paper, but in practice.
  2. Your privacy matters. This form includes a HIPAA-compliant Business Associate Agreement (BAA) and a Non-Disclosure Agreement (NDA) for your full protection. Please sign and return them as part of this packet.
  3. Completeness is key. The form must be completed in full before we can proceed to underwrite or issue a proposal.
  4. Need help? If one of our specialists is not assisting you directly, please complete the form online via our secure DocuSign system. Alternatively, you may print and complete it manually, sign it, and return it to CashRX@pfdcap.com.

FAQ’s: 


  1. Our goal is to make sure we learn a little bit about each other so we can truly be of service to you.
  2. For your protection, this document includes a BAA and NDA and it must be signed and returned.
  3. Also, this form MUST BE FILLED OUT IN ITS ENTIRETY for us to move forward to the next step in funding.

What can PFD offer you?
Whether you’re looking to sell receivables outright, secure short-term business cycle financing, or implement a white-labeled solution, our experienced team brings creativity, discipline, and proven results to the table.

How do we protect your confidentiality?
Every step of our process is private, HIPAA-compliant, and built on trust. We operate with the highest standards of discretion and care.

What happens next?
Once your completed form is received:

  • We’ll begin underwriting and develop a customized proposal based on your specific needs.
  • Our analytics team will review your historical collections, recovery rates, and open A/R.
  • After final review, we’ll issue a firm commitment. If approved, funding can occur in as little as two weeks.

Whether or not we connect in real-time, completing this application will be a valuable exercise for your practice. We look forward to the opportunity to serve you.

Warm regards,
The New Accounts Team
PFD Management

Trusted by medical professionals. Built for your success.

Thank you, PFD Management, LLC.

Step 1 of 4

PROVIDER INFORMATION

If YES, a separate intake form must be completed.