800-501-3897 · Get Started Now · Login

Patient Payment Solutions Application

Legal business name as it appears on your federal tax return*
Doing Business as (DBA)
Type of business*
Address
Phone
Fax
Email*
Business Opened Date*
Federal Tax ID*
Tax Filing State*
Owners First Name*
Owners Last Name*
Owner's Social Security Number*
Ownership Percentage (Must be at least 51%)*
Products/Services Sold
How did you hear about us
By signing your name, you have read and agree to the Patient Payment Solutions Service Agreement Terms and Conditions
By signing your name, you have read and agree to the Patient Payment Solutions Client Pricing
By signing your name, you have read and agree to the HIPAA Business Associate Agreement