CarePay Application Form

CAREPAY APPLICATION FORM

Provider*
Estimated Dollar Amount Requested*
Please enter a number less than or equal to 20000.
(Approximate total of the procedure or deductible)
Payment Plan*
What are Micro–Payments? We understand that large monthly payments can wreak havoc when life throws you an unexpected curveball. CarePayUSA helps alleviate this burden by fracturing your monthly payment into miniature auto-deducted daily payments. Your large monthly payment can be easily digested into a daily price that is often less than the cost of your lunch. (Example, a $250 monthly payment could be as low as only $8.33 per day). Don’t let life catch you off-guard, choose micropayments today, and enjoy a new way to manage your payments!
Required Down Payment
Monthly Payment
Required Down Payment
Daily Payment
PATIENT/APPLICANT INFORMATION:
First Name*
Patient first name
Last Name*
Patient last name
Middle Name
Patient middle name
Phone*
Email*
Date of birth*
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Housing Payment
Years at Current Job*
Employment Status*
Gross Monthly Pay
Other Income Source
Other Income (Monthly)
Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation. Alimony, child support, separate maintenance received under:
- Court Order
- Written Agreement
- Oral Understanding
Will There Be a Co-Applicant?*
- Yes
- No
If you intend to apply for joint credit, please initial here
Doctor Information
Doctor's Full Name (First and Last Name)
Phone Number for Doctor's Office
Address of Doctor's Office
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I agree that a staff member may submit this application on my behalf to CPU. I also agree that this application and any information I submitted with it may be forwarded to other creditors. By signing below, I further agree that such other creditors may obtain a credit report and rely on it making a credit decision. Governing Law. The validity, interpretation, and enforcement of this Agreement and its terms and conditions shall be interpreted and governed under the laws of the State of Colorado.
Borrower Signature*
Comments
This field is for validation purposes and should be left unchanged.

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(844-929-2729)
info@carepay.com

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CAREPAY APPLICATION FORM

PATIENT/APPLICANT INFORMATION:

Doctor Information

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