Provider Application

Legal Entity Information

All fields are required unless marked optional

Legal Business Name * Exactly as registered with the state

DBA (if applicable)

Entity Type *

Date Entity Was Formed *

State of Incorporation *

Federal Tax ID (EIN) *

Business Website *

Business Email * No personal email addresses

Business Phone *

Fax

Physical Address

Street Address *

City *

State *

ZIP Code *

Country *

Mailing address is same as physical address

Ownership & Control

All owners with ≥10% ownership must be disclosed

Why we need this:

Federal regulations require financial platforms to verify beneficial ownership. This protects against fraud and ensures compliance with KYC (Know Your Customer) requirements.

Owner #1

Full Legal Name *

Title/Role *

Ownership Percentage *

Date of Birth *

Social Security Number * Encrypted and secured. Required for identity verification.

Email *

Phone *

Home Address *

City *

State *

ZIP Code *

Government-Issued ID Upload *

Click to upload Driver's License or Passport

PDF, JPG, or PNG • Max 5MB

I certify that all ownership information is accurate and complete under penalty of perjury.

Medical & Provider Credentials

Healthcare-specific credentials and licensing information

Practice Type *

Other Practice Type (if applicable)

NPI Number (Individual) * 10-digit National Provider Identifier

NPI Number (Organization)

State Medical License Number *

License Issuing State *

License Expiration Date *

DEA Number (if applicable)

Medicaid Provider Number

Medicare PTAN

Financial & Banking Information

Required for PayFlex settlement and provider payouts

Banking Information:

Banking information is required to enable PayFlex settlement and provider payouts. All data is encrypted and stored securely in compliance with PCI DSS standards.

Bank Name *

Account Type *

Routing Number * 9-digit routing number

Account Number *

Name on Account * Must match business legal name

Upload Void Check or Bank Letter *

Click to upload void check or bank verification letter

PDF, JPG, or PNG • Max 5MB

Program Participation

Services Eligible for PayFlex *

Copays

Coinsurance

Deductibles

Non-covered services

Average Out-of-Pocket Cost per Patient *

Estimated Monthly PayFlex Volume *

Preferred Payout Schedule *

I understand PayFlex enables patient access while accelerating provider collections.

Tax & Compliance Documents

All documents required before application approval

Document Requirements:

All documents must be current, legible, and match the information provided in this application. Documents are reviewed during underwriting and may take 3-5 business days to process.

W-9 (signed) *

Click to upload completed and signed W-9

PDF only • Max 5MB

Articles of Incorporation / Organization *

Click to upload Articles of Incorporation/Organization

PDF only • Max 5MB

Operating Agreement or Corporate Bylaws *

Click to upload Operating Agreement or Bylaws

PDF only • Max 5MB

Professional Liability Insurance (COI) *

Click to upload Certificate of Insurance

PDF only • Max 5MB

I attest that my practice is HIPAA compliant

I acknowledge that PayFlex handles all payment processing in compliance with PCI DSS standards

Review & Sign

Review your application and provide electronic signature

Legal Acknowledgments:

By signing this application, you agree to all terms and conditions outlined in the PayFlex Systems Provider Program Agreement. All information provided is accurate and complete under penalty of perjury.

I agree to the Terms of Service

I agree to the Provider Program Agreement

I authorize ACH transactions for settlement and payouts

I consent to Data Sharing & KYC verification

I certify that all information is true and accurate (Anti-Fraud & Misrepresentation)

I agree to the Arbitration Agreement

I consent to use Electronic Signatures

Electronic Signature

Signature Method:

Sign with mouse, touchscreen, or stylus:

Title *

Date *

Legal Notice: Your signature, IP address, timestamp, location data, and device information will be captured and encrypted for verification and compliance purposes. This constitutes a legally binding electronic signature under the ESIGN Act.

Legal Entity Information

Physical Address

Mailing Address

Ownership & Control

Medical & Provider Credentials

Financial & Banking Information

Program Participation

Tax & Compliance Documents

Review & Sign

Electronic Signature