PPS Full Application IMPORTANT: Please have available the following documents: PDF/JPG copy of your clinic’s voided check Color copy front and back of the Owner’s drivers license PPS Application To complete your clinic application, we require a one time $299 application processing fee. The information is 100% protected and is in compliance with The US Patriot Act of October 2001. If you are referred by one of our PPS affiliates, please let us know.Legal business name as it appears on your federal tax return* Doing Business as (DBA) Type of Business* S Corp C Corp LLC Sole Proprietary Not Listed What type of LLC C Corp Disregarded Entity Partnership S Corp Sole Proprietor Number of Owers 1 Owner 2 Owners Name Owner’s First Name Owner’s Last Name Birthday* MM slash DD slash YYYY 2nd Owner's Name 2nd Owner’s First Name 2nd Owner’s Last Name Birthday MM slash DD slash YYYY Clinic Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone* Fax*If you do not have a fax enter 000-000-0000 Documents Required Please upload documents requested and Complete Application – Or – If preferred, Complete Application then email the documents directly to: info@ppscollect.com including name of clinicHiddenCopy of a Clinic Utility BillAccepted file types: jpg, pdf, png, Max. file size: 30 MB.Copy of a Clinic Voided CheckAccepted file types: jpg, pdf, png, heic, Max. file size: 30 MB.HiddenCopy of a Professional LicenseState issued license (MD, DC, DDS, NP, etc)Accepted file types: jpg, pdf, png, Max. file size: 30 MB.COLOR COPY FRONT of your driver's licenseWe need a color copy of both front and back of your active driver license. If there are multiple owners, we will need each owner’s driver’s license.Accepted file types: jpg, pdf, png, heic, Max. file size: 30 MB.Copy of business license or utility billWe need a copy of either your business license or utility bill.Accepted file types: jpg, pdf, png, heic, Max. file size: 30 MB.Business Opened Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Federal Tax ID* Owner's Social Security Number* Ownership Percentage* 2nd Owner's Social Security Number 2nd Ownership Percentage Products/Services Sold*Which option best describes your business. Chiropractic Medical Dental Weight Loss Stem cell HiddenChoose one of the following Yes, I would like the ability to offer Auto Debit Payment Plans for my patients No, I do not want to offer Auto Debit Payment Plans. How did you hear about us? Internet Search Facebook Friend Publication AMI Seminar/Event Ninja Your Full Name – Service Agreement*By signing your name, you have read and agree to the Patient Payment Solutions Service Agreement Terms and Conditions. Click here for a copy of the Patient Payment Solutions Terms and Conditions. 2nd Owner's Full Name – Service AgreementBy signing your name, you have read and agree to the Patient Payment Solutions Service Agreement Terms and Conditions. Click here for a copy of the Patient Payment Solutions Terms and Conditions. Your Full Name – HIPAA Agreement*By signing your name, you have read and agree to the HIPAA Business Associate Agreement. Click here for a copy of the HIPAA Agreement. 2nd Owner's Full Name – HIPAA AgreementBy signing your name, you have read and agree to the HIPAA Business Associate Agreement. Click here for a copy of the HIPAA Agreement. Referral Code Application Fee Price: Application Fee Price: Application Fee Price: Application Fee Price: Application Fee Price: Application Fee Price: Credit Card Cardholder Name Card Details CAPTCHAAll fields marked with an ( * ) are required. Please double check required fields before submitting the form.
