AMP ENROLLMENT
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Practice Name:
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Legal Name:
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Merchant Name (name that appears on credit card statements):
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Practice Address:
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Practice Phone:
Merchant Billing Address:
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Billing Contact (name):
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Billing Contact (email):
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Billing Contact (phone):
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Withdrawal account information (Bank name):
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Account number:
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Routing number:
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Practices will opt in to the following:
5% provider practice fee, monthly auto withdrawals of the 5% provider practice fee, marketing efforts including but not limited to: Lane Health' flyers in practice office, Lane Health banner on practice website, practice to email patients directly bi-monthly regarding the availability of LaneHealth. 'Lane Health is a financial technology company, not a bank. The Healthcare Spending Card is issued by Lead Bank. Individuals can apply for a line of credit with no credit checks, potentially helping more people qualify as other factors are considered when granting credit. Visitwww.lanehealth.com for more details
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