Clone of Core Ascent 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.)*
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Phone Number*
Format: (000) 000-0000.
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.Format: (000) 000-0000.
Contact person's email if different than above
example@example.com
What is your Practice website?*
What is the Doctor's or Owner's name*

First NameLast Name
How many loans do you close every month?*
What is your average loan amount?*
Please list the patient financing companies you are currently using.
Please review the following lender program options, and let us know which of these programs you would like to enroll to use. NOTE: These are third party lender programs.
YesNoI would need to learn more.
YesNoI would need to learn more.
YesNoI would need to learn more.
YesNoI would need to learn more.
YesNoI would need to learn more.
Fee Disclosure:

We will charge each of your customers a User's Fee of $375 if they get approved and they accept a loan offer. As long as you close one loan a month leading to a minimum collection of $375, we will not charge you any fees. But if you have a month in which you do not generate a minimum of $375 in fees, we will send you an invoice for $375 for that month. As to how we collect the fee from your customer... We can program your financing platform to require the Applicant to enter a credit or debit card payment method, or to have the fee added to the loan amount. If we collect the payment method upfront from the Applicant, it will only be charged after we verify the application was approved. If you allow them to add the fee to the loan amount, it will get paid to your Practice and you will be responsible for paying our invoice after you have been funded.
YesNo, cancel my enrollment
Yes, collect the fee directly from the Applicant.No, invoice my business for each funding fee.
One Time Set Up Deposit:

To avoid a Practice from signing up "just because it is free"... We charge a one-time set up deposit fee of $375. This fee must be paid at the time you enroll. However, this fee will be credited back to you after six months using the platform. PLEASE NOTE: We will send you an invoice for this deposit after we receive this form back.
YesNo, cancel my enrollment
Enrollment Term:

This agreement will be based on a month-to-month agreement that can be cancelled by either party with a 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.
What happens next:

Once we receive your enrollment request, we will contact your Practice and discuss the lender programs you are interested in enrolling to use. Then we will send you a check list of the documents each lender will require you to provide for their enrollment, and another form like this that you can use to upload those documents. As soon as we get those documents back, we will start your enrollments with the lenders. Most of the lenders will take between 7 and 10 business days to approve your practice and set you up. But don't worry, we will be here to support the process and push it along the way.
Thank you for submitting your enrollment request. If you have any questions or concerns, please call (844) 995-4657.
PRIME RX
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Enrollment Agreement

Fee Disclosure:

One Time Set Up Deposit:

Enrollment Term:

What happens next: