Enrollment Agreement and Questionnaire

We appreciate your interest in enrolling with Finance Your Care, a division of Credit Technologies. Please provide the information below so we can set up your Practice and match you with the lenders in our portfolio best suited to your needs. For any questions, please contact Patricia at 877-600-1031 or patricia@fycla.com.

Practice Information:

What is the legal name of your Practice (please include LLC, etc)

What is your Practice Specialty (i.e. Chiropractic, Plastic Surgery, etc.)

What is the Doctor's name

First NameLast Name

What is the Owners name if different

First NameLast Name

Practice Address

Street Address

Street Address Line 2

CityState

Zip Code

Practice Phone Number*

Please enter a valid phone number.

Practice Email

example@example.com

Who is the Contact Person we should call or email?

First NameLast Name

Contacts Direct Phone Number if different from main number

Please enter a valid phone number.

Contact persons email if different than above

example@example.com

Practice website

Enter the expiration date for the card:

Practice Financing Profile

In the following section, we will request information about your gross sales, existing financing activity, and average loan volume. This data allows Finance Your Care to align your Practice’s financial profile with the most suitable lenders available through our platform.

What are your Practice Gross annual sales

What is your average loan amount

How many loans do you close every month?

Please list the Patient Financing companies you are currently enrolled with separated by comma's. If you are not offering Patient Financing at this time, just enter "None".

Finance Your Care Fee Structure

Refundable Setup Fee / Deposit

Finance Your Care invests significant time and resources in onboarding each new Practice. To ensure enrollment reflects a true intention to use the platform, we collect a $375 setup fee at the time of enrollment. After your Practice completes its first transaction and Finance Your Care has collected the processing fee, the $375 setup fee will be credited back to your Practice.

Enrollment in Patient Financing Technology

By enrolling in our program, your Practice agrees that the Patient/Applicant will be responsible for paying all fees associated with using the Finance Your Care platform. The fees are:

Loan amounts up to $10,000 → $395
Loan amounts above $10,000 → $595

When quoting your price, please include this fee if the Patient/Applicant chooses to finance. The fee will be paid to your Practice when the lender disburses funds for the transaction. Three days after funding, Finance Your Care will automatically invoice your Practice to collect the fee and charge the credit or debit card you have on file.

Practice Card Authorization for Fees

Please provide a credit or debit card for payment of the deposit and any future charges from patient financing fundings.

Enter the name as it appears on the credit or debit card you want to use.

First NameLast Name

Enter your account number:

Enter the security code for this card

Enter the mailing address for the card if different from above:

Please click on an option. Do you authorize Credit Technologies / Finance Your Care to charge the credit or debit card you have listed on this enrollment form for our security deposit in the amount of $375.*

YesNo

Referral Acknowledgment

We greatly appreciate the time and dedication our Representatives invest in explaining our program and highlighting its benefits. If your Practice was referred by one of our Business Development Representatives, please select their name from the menu below, or choose Default if none applies.*

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 Patricia at (877) 600-1031 or email at Patricia@fycla.com.

Thank you!

FYC LA Enrollment Agreement