Health Pay Plus Application Form

Health Pay Plus

Application Form
Please verify that you are human*

Merchant Contact Information
Contact Name*

First NameLast Name
Contact Date of Birth*

MonthDayYear
Contact Email*
example@example.com
Contact Phone Number*
Please enter a valid phone number.
Merchant Business Information
Legal Name of Business*
DBA Name of Business*
Type of Ownership*
Business Phone Number*
Please enter a valid phone number.
DBA Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Exact Start Date*

MonthDayYear
Is the legal information the same as the DBA information?*

NoYes
Legal Address (if different than Business)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Federal Tax ID Number*
Website
Business Profile
What is the business type?*
Years in Business*
Estimated Monthly Volume*
Estimated Average Ticket*
Estimated Highest Ticket*
Owner's Information
Owner / Managing Partner Name*

First NameLast Name
Owner Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Owner Email*
example@example.com
Owner Date of Birth*

YearMonthDay
Primary Phone Number*
Please enter a valid phone number.
Social Security Number of Owner / Managing Partner*
Percent of Ownership *
Additional Owner's Information
Are there additional owners with 25% or more?*

YesNo
Additional Owner Name

First NameLast Name
Additional Owner Email
example@example.com
Additional Owner Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Owner Date of Birth

YearMonthDay
Additional Owner Primary Phone Number
Please enter a valid phone number.
Additional Social Security Number of Owner / Managing Partner
Percent of Ownership
Add an Authorized User
Would you like an additional authorized user?

YesNo
Additional Authorized Contact Name

First NameLast Name
Additional Authorized Contact Phone Number
Please enter a valid phone number.
Additional Authorized Contact Date of Birth

YearMonthDay
Account Setup
Advantage Program (Credit Card)
Simplechange (Credit Card)
Do you want Digital Checking (ACH)?

YesNo
Cost: $2.50 per check and .50% over $10,000

ACH (Automated Clearing House) payments offer a powerful alternative for customers who prefer to avoid credit card fees, making it a valuable secondary payment option for any business. With digital ACH, customers can pay directly from their bank account, often with no transaction fees—helping businesses reduce processing costs while giving clients a fee-free payment option.
Supporting Documents
Driver's License for Each Owner*

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Image Of Voided Check OR Bank Letter*

Cancelof
Statements (Require 3 month bank statement for your company to accept digital check payments. This is solely to verify that your account typically has a daily balance which is able to cover returned checks and to verify that you have a positive checking history.)*

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Select Your Terminal
Product List
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MagTek Dynamag Credit Card ReaderMagtek Credit card reader is a simple, inexpensive solution. Plugs directly into your computer's USB port and connects directly to your Sky Payments Group gateway. Includes power cable and mounting tape. Simple, inexpensive, effective and efficient payments. Cost: Free when you Board with Health Pay Plus* *additional readers $89.99
$89.99 Quantity



6200M WiredThe Luxe 6200m from Equinox is a smart, compact, and modern payment device. It features a 2.4” multimedia touchscreen display with signature capture and a wear-resistant keypad. Built on Linux OS, the 6200m meets strict security standards, accepts all forms of payments, and can run a full suite of value-added applications to elevate the user experience. (Recommended)
$399.00 Quantity



6200M WirelessThe Luxe 6200m from Equinox is a smart, compact, and modern payment device. It features a 2.4” multimedia touchscreen display with signature capture and wear-resistant keypad. Built on Linux OS, the 6200m meets strict security standards, accepts all forms of payments and can run a full suite of value-added applications to elevate the user experience. Best of all it's completely wireless. Take it to where your patients are or leave it as a wire-free countertop terminal.
$450.00 Quantity



8500MEnhance the payment experience for your customers’ business with the Luxe 8500i payment terminal. The Luxe 8500i features a high-definition 5” touch display, signature capture, a horizontal layout, top-mounted card reader, and the ability to accept all forms of payments. Powered by an advanced operating system, the 8500i supports integrated, semi-integrated, and hybrid POS interfaces.
$499.00 Quantity



Total

$0.00
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Finishing Up
Hurray! You're done. Just click submit your application.

We will contact you if we need anything else!
Should be Empty:

Health Pay Plus

Merchant Contact Information

Merchant Business Information

Business Profile

Owner's Information

Additional Owner's Information

Add an Authorized User

Account Setup

Supporting Documents

Select Your Terminal

Finishing Up

Hurray! You're done. Just click submit your application.