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Patient Payment Solutions PROVIDER Application

Legal business name as it appears on your federal tax return*
Doing Business as (DBA)
Type of business*
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

Financial Disclaimer and Notice of Privacy Practices:

Typical Patient Payment Solutions provider offices increases patient collections between 10-56%, however, these results in no way guarantee how your specific clinic will perform.   Implementation of financial payment policies is the responsibility of the clinic administrator and staff.  For any additional questions about successful implementation, please contact one of our staff members.

Patient Payment Solutions creates and stores information consistent with HIPAA, DSS, and PCI standards and procedures for all patients and clinic applications.  Clinic/Patient correspondence outside of website-based information may contain confidential or legally privileged information or private and sensitive healthcare information that is intended to be shared only with the named recipient. Any enclosed healthcare information may be protected under the Privacy Act, 5 USC 552 (a), and/or Health Insurance Portability and Accountability Act (HIPAA) (PL104-191) and its various implementing regulations. If this correspondence contains healthcare information, it is being provided to you after appropriate authorization from the patient or under circumstances that do not require patient authorization. Recipients are obligated to maintain it in a safe, secure, and confidential manner and this information must be protected in accordance with those provisions.  Redisclosure without additional consent or as permitted by law is prohibited. If you are not the intended recipient, any review, use, dissemination, distribution or copying is strictly prohibited.