MedPlan Credit Patient Application

FINANCING APPLICATION FORM

Apply for healthcare financing in seconds.

In an effort to make care accessible to all of our patients regardless of their financial situation, we have partnered with MedPlan Credit to provide patient-friendly payment plans that can fit most budgets. Unlike credit cards, MedPlan provides installment loans with a fixed interest rate, much lower than credit card rates. For a small one time enrollment fee, MedPlan loans provide affordable payments that can be spread out monthly to fit your budget to ensure that you get the care that you need.

Credit Amount Requested
Select monthly terms that work for you.

Payments over months selected.

Estimated Monthly Payments: $

Estimated One Time Enrollment Fee: $

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.