Clone of FYCSFL Enrollment Agreement

Enrollment Agreement

Thank you for your interest in enrolling with Finance Your Care. Please complete the information below so we can get your Practice set up, and we can identify the lenders in our portfolio that will be the best fit for your Practice. If you have any questions, please call (844) 995-4657.
What is the legal name of your Practice*
Make sure you include (LLC, PA, Inc)
What is your Practice specialty (i.e. Chiropractic, Plastic Surgery, etc.)*
What is the Doctor's name

First NameLast Name
What is the Owner's name (if different)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
What is the Practice email*
Who is the contact person we should call or email?*

First NameLast Name
Contact person's phone number if different than above
Please enter a valid phone number.
Contact person's email if different than above
example@example.com
What is your Practice website?*
The next section ask about your gross sales, current lending options, and average loan volume. This is asked so we can match your current offers with the lenders in our portfolio that should help get more approvals for your patients.
What are your Practice Gross Annual Sales*
How many loans do you close every month?*
What is your average loan amount?*
Please list the Patient Financing companies you are currently enrolled with. If you are not offering Patient Financing at this time, just enter "None"*
Fee Disclosure:

Your Practice is always considered as "our client". As such, your Practice is always the client being billed for each closing and then responsible for paying the fee(s) for our services. The fee we charge on each closed and funded transaction is based on the following chart: Loan amounts up to $2000; the fee is $175. For loan amounts between $2000.01 and $10,000, the fee will be $375. All loan amounts of $10,000.01 and/or above, the fee will be $575. This fee can be passed on to the Applicant, and they can add it to the amount financed. However, you must fully disclose this fee as a "loan set up fee". Each time your Practice closes a loan through any lender after using our pre-qualification platform, the fee becomes due and payable. Finance Your Care will collect our fee by sending you a monthly or bi-weekly invoice (based on your volume). You will then be given 3 business days to review the invoice and dispute any of the pending charges. On the fourth business day, the invoice will be charged to a payment method you put on file for future payments.
Do you understand and agree to the fee disclosure as outlined?*

YesNo, cancel my enrollment
Potential Monthly Fee:

As a part of your enrollment and the technology we set up for your Practice... Finance Your Care will build and host a financing platform for your Practice that includes your current financing options as well as the lenders we connect to your Practice financing options. To offer this platform, we incur on-going monthly costs. To offset that cost, if you have a month in which you do not close a minimum of one loan, we will charge you a $375 fee for that month using the payment method you list on file.
Do you understand and agree to the potential monthly fee as outlined?*

YesNo, cancel my enrollment
Enrollment Disclosure:

Finance Your Care offers a financing platform for Healthcare Providers to use in securing patient financing options for their patients. We do not approve, deny, set the rate or terms on any loan that may be offered, and we do not extend credit in any way. When you contract with Finance Your Care; you are doing so to use our platform and have the opportunity to use the lenders in our portfolio. There is no other service being offered as a part of this agreement.
Enrollment Term:

This agreement will be based on a month-to-month agreement that can be cancelled by either party with 30 days notice. However, if you have an outstanding balance at time of cancellation, you will be required to pay that balance within 30 days.
Final Steps:

After you submit this form, we will complete your onboarding with Finance Your Care, and assign your Practice with a Provider ID. After doing so, we will send you back an email with your Provider ID and schedule a call with you to discuss the lender options. Once we know which of our lenders (and yours) you want to work with, we will complete your lender onboarding and get your platform completed. If you have any questions, please call (844) 995-4657. Thank you!
FYCUT
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Enrollment Agreement

Fee Disclosure:

Potential Monthly Fee:

Enrollment Disclosure:

Enrollment Term:

Final Steps:

FYCUT