Merchant Registration - United Credit

Apply to become a United Credit Merchant

A team member will get back to you within one business day with the status of your application.

If you have any questions contact enroll@unitedcredit.com.

Company

Corporate or Legal Name *

Business Name/DBA (if different)

Federal Tax ID number *

Address *

City *

State *	Zip code *

Primary Office Phone *

(

)

Secondary Office Phone

(

)

Primary Office Fax

(

)

Primary Professional Specialty *

Company website

Number of locations*

Primary Contact Full name*

Primary Contact Email *

Type of Ownership*

Date Company Opened *

Average Financed Amount*

Estimated Annual Financing*

Medical and/or Business License Number*

Company Owners/Officers

Owner 1

Full Name *

Title *

Percentage Owned *

Address *

City *

State *	Zip code *

Date of Birth *

Personal Email*

Personal Cell *

(

)

Social Security Number *

Enter details of Owner 2

Owner 2

Full Name *

Title *

Percentage Owned *

Address *

City *

State *	Zip code *

Date of Birth *

Personal Email*

Personal Cell *

(

)

Social Security Number *

Application Verification

We need to verify your information

Please upload a voided Check to help verify your account information (must be .jpg image)

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.

I have read, understand and accept the above terms Name: Date: 03/26/2023

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