UNITED CREDIT PROFESSIONAL APPLICATION. Submission of United Credit Professional Application
("Application") establishes a consumer financing program with United Medical Credit, Inc. for the above-named person or legal
entity ("Provider") the terms of which are set forth in this Network Registration (Provider Direct) Form and the United Credit
Provider Direct Terms and Conditions. By submitting this form, Provider hereby represents, acknowledges, agrees, authorizes and
confirms the following:
- If Provider is a legal entity, the applicant is executing this application as an officer of the Provider.
- If Provider is sole proprietorship, the applicant is executing this Application in his or her individual capacity.
- Provider has reviewed all provisions of this Application and all information provided herein is true and complete.
- The above Tax ID number is the correct taxpayer identification number for the Provider.
- Provider agrees to all terms and provisions of the United Credit Provider Terms and Conditions ("Terms and Conditions") and the HIPAA BAA which are incorporated by reference. You agree that United Credit may amend such Terms and Conditions, and you agree to be bound the Terms and Conditions and the HIPAA BAA that are set forth at https://www.unitedcredit.com/provider-terms/ at the time of signing the UC Disbursement Form.
Please carefully read the United Credit Provider Terms and Conditions and the HIPAA BAA that are available here
and incorporated herein by reference. By submitting this form, you are
entering into a binding contract with United Medical Credit, Inc., which shall govern the submission of transactions for
financing. If Provider is a legal entity the signatory hereto represents and warrants that he or she is authorized to execute
the Agreement on behalf of, and to bind, Provider on whose behalf he or she signs this Agreement.