MedPlan Credit Patient Application

FINANCING APPLICATION FORM

Apply for healthcare financing in seconds.

How it works: By partnering with physicians and hospitals, MedPlan is able to provide affordable payment plans for patients with high deductibles or other large out-of-pocket medical bills.

Apply for healthcare financing in seconds.
What you'll need to apply:

Your bank account number

Your routing number

Your online banking username and password

MedPlan uses your online banking login to verify that you have a bank account and to ask your bank some questions that allow us to approve your application right away! Don't worry, we can't make any withdrawals until you give us permission. If you don't have online banking, you can still apply and we'll give you a decision in less than 2 days.

Healthcare Provider

First Name

Middle Name

Last Name

Primary Phone Number

Secondary Phone Number

Confirm Email

Add Provider Email (Only needed if your provider requires)

Provider Email

Address

Address2

City

State/Province

Postal Code

Social Security Number

Date of Birth

# of Dependents (Include Self)

Own/Rent

Monthly Mortgage or Rent Payment

Employment Status

Are you currently employed?
Retired, SSI, Disability or Unemployed is not considered valid employment

Occupation

Employer

Start Date

Previous Employer

Start Date

End Date

Deposit Pay Cycle

Account Type

Deposit Amount

Please Enter Card Information
No charge to your card until your loan process is complete with authorized signature.

Setup Fee Payment Method

Card Holder Name

Card Number

Card CVC Number

Card Expiration Month

Card Expiration Year

Authorization

I understand that I am applying for credit and I hereby authorize Medplan Credit to obtain my credit information.
I attest this is true and correct information.
Incorrect Information may result in denial of loan application and forfeiture of enrollment fee.

FINANCING APPLICATION FORM

Apply for healthcare financing in seconds.

How it works: By partnering with physicians and hospitals, MedPlan is able to provide affordable payment plans for patients with high deductibles or other large out-of-pocket medical bills.

Payments over months selected.

Estimated Monthly Payments: $

Estimated One Time Enrollment Fee: $