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Business name used with patients (i.e. DBA)

This is the name used for things like store signage and marketing. DBA = Doing Business As

Legal Business Name

Legal Business Name must match your tax documents

Legal Entity Type

Business Address

City

State

Zip

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Primary Contact First Name

Primary Contact Last Name

Primary Contact Email

Primary Contact Phone (No Dashes)

Website URL

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Business Open Date

This is the date the business filed for the TaxID with the Secretary of State

Merchant Category Code

Type of Goods/Service Sold

E.g. Dentistry, Physical Therapy

Federal Tax ID # (No Dashes)

Application Signor Name (must have financial signing authority for the business)

Example: John Doe

Signatory Job Title

Signatory Date of Birth

Signatory Signor SSN (No Dashes)

To comply with U.S. law, financial institutions are required to verify identity when providing access to payment services. This includes confirming your identity by collecting personal information (such as Social Security Number and and home address) as mandated by the Patriot Act and the Anti-Money Laundering Act of 2020. These steps help prevent fraud, money laundering, and terrorism financing.

Signatory Email

Signatory Phone Number

Signatory Physical Home Address

Must be the signatory's physical home address - not the business's or a PO Box.

Signatory Home City

Signatory Home State

Signatory Home Zip

Does Signatory have 25% or more ownership of the company?

What percentage of the business does the Signatory own (note: this could be 0%)?

Example: 60, 100

According to federal regulations (Patriot Act and the Anti-Money Laundering Act of 2020) all business owners with a 25% or more share in the business must be documented below. How many business owners have 25% or more share? Select zero if the Signatory is also the only person with 25% or more ownership.

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Beneficial Owner #1 Name

A beneficial owner of a business is an individual who, either directly or indirectly, owns or controls at least 25% of the company's ownership interest or exercises substantial control over the company.

Beneficial Owner #1 Job Title

Beneficial Owner #1 DOB

Beneficial Owner #1 SSN (No Dashes)

To comply with U.S. law, financial institutions are required to verify identity when providing access to payment services. This includes confirming your identity by collecting personal information (such as Social Security Number and and home address) as mandated by the Patriot Act and the Anti-Money Laundering Act of 2020. These steps help prevent fraud, money laundering, and terrorism financing.

Beneficial Owner #1 Email

Beneficial Owner #1 Phone Number

Beneficial Ownership Percentage #1

Example: 60, 100

Beneficial Owner #1 Physical Home Address

Beneficial Owner #1 Home City

Beneficial Owner #1 Home State

Beneficial Owner #1 Home Zip

Beneficial Owner #2 Name

A beneficial owner of a business is an individual who, either directly or indirectly, owns or controls at least 25% of the company's ownership interest or exercises substantial control over the company.

Beneficial Owner #2 Job Title

Beneficial Owner #2 DOB

Beneficial Owner #2 SSN (No Dashes)

To comply with U.S. law, financial institutions are required to verify identity when providing access to payment services. This includes confirming your identity by collecting personal information (such as Social Security Number and and home address) as mandated by the Patriot Act and the Anti-Money Laundering Act of 2020. These steps help prevent fraud, money laundering, and terrorism financing.

Beneficial Owner #2 Email

Beneficial Owner #2 Phone Number

Beneficial Ownership Percentage #2

Example: 60, 100

Beneficial Owner #2 Physical Home Address

Beneficial Owner #2 Home City

Beneficial Owner #2 Home State

Beneficial Owner #2 Home Zip

Beneficial Owner #3 Name

A beneficial owner of a business is an individual who, either directly or indirectly, owns or controls at least 25% of the company's ownership interest or exercises substantial control over the company.

Beneficial Owner #3 Job Title

Beneficial Owner #3 DOB

Beneficial Owner #3 SSN (No Dashes)

To comply with U.S. law, financial institutions are required to verify identity when providing access to payment services. This includes confirming your identity by collecting personal information (such as Social Security Number and and home address) as mandated by the Patriot Act and the Anti-Money Laundering Act of 2020. These steps help prevent fraud, money laundering, and terrorism financing.

Beneficial Owner #3 Email

Beneficial Owner #3 Phone

Beneficial Ownership Percentage #3

Example: 60, 100

Beneficial Owner #3 Physical Home Address

Beneficial Owner #3 Home City

Beneficial Owner #3 Home State

Beneficial Owner #3 Home Zip

Beneficial Owner #4 Name

A beneficial owner of a business is an individual who, either directly or indirectly, owns or controls at least 25% of the company's ownership interest or exercises substantial control over the company.

Beneficial Owner #4 Job Title

Beneficial Owner #4 DOB

Beneficial Owner #4 DOB (No Dashes)

To comply with U.S. law, financial institutions are required to verify identity when providing access to payment services. This includes confirming your identity with a government-issued ID and Social Security Number, as mandated by the Patriot Act and the Anti-Money Laundering Act of 2020. These steps help prevent fraud, money laundering, and terrorism financing.

Beneficial Owner #4 Email

Beneficial Owner #4 Phone

Beneficial Ownership Percentage #4

Example: 60, 100

Beneficial Owner #4 Physical Home Address

Beneficial Owner #4 Home City

Beneficial Owner #4 Home State

Beneficial Owner #4 Home Zip

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Annual volume of claim payments processed

How many dollars in claim payments did you process last year?

Average claim payment value

What is the average claim payment that you process?

Highest claim payment value

What is the highest claim payment that you process?

Bank Name

Routing #

Bank Account #

Voided Check or Bank Verification Letter (pdf, jpeg, png)