About 8 minutes

Share your location's information

Complete this form and we'll share it with Happen Bank, who will prepare your Participating Provider Agreement and send it to you for review and signature. Each section is short, and the progress panel keeps track of where you are.

Have these ready before you begin

Business tax ID (EIN), or SSN if you use it in place of an EIN
Legal business name and any DBA
Owner's date of birth and ownership percentage
Bank routing and account numbers (a voided check works)
Office and headquarters addresses
Names and emails for your office and primary contacts

Internal pre-launch checklist (hidden when preview mode is off)

Pending: deploy the backend (see backend/README.md) and set ENDPOINT in this file. Until then, nothing is sent anywhere
Pending: host this page over HTTPS at the address set as ALLOWED_ORIGIN
Pending: set PREVIEW_MODE and SHOW_FIELD_SECURITY_NOTES to false once the backend is live and tested
Pending: set up the sign-in for the secure submissions page and confirm Happen Bank is comfortable with the secure-link method
Pending: legal review of the disclosures, consent and privacy wording
Pending: confirm the support phone and email in the footer (taken from the website; the email is the "approvals" mailbox)

Location type

Tell us whether this business operates one location or several.

Location type

Single locationOne business at one address.

Multi-locationA group with more than one location. Submit one form per location.

Business information

Use the names exactly as they appear on your tax and formation documents.

Legal business name *

DBA (if different from legal name)

Business type *

Tax ID *

Enter your EIN. If you use your SSN in place of an EIN, enter that instead.

PendingEnhanced encryption and access controls for this field are still being set up.

Location

The physical address of this location.

Location name *

How this location is known day to day, for example "Downtown Clinic".

Street address *

City *

State *

ZIP code *

Owner

Details for the business owner. These help us verify your information.

Owner's first name *

Owner's last name *

Owner's date of birth *

PendingEnhanced encryption and access controls for this field are still being set up.

Ownership percentage *

Enter a number from 1 to 100.

Office contact

The person we should reach for day-to-day questions about this location.

Office contact name *

Email *

Office phone *

Office address

Same as the location address above

Office address *

Address 2 (suite, floor, unit)

City *

State *

ZIP code *

Corporate headquarters

Where the business is headquartered.

Same as the office address

Corporate / headquarters address *

City *

State *

ZIP code *

Primary contact

The main point of contact for your Patient Capital account.

Same as the office contact

Primary contact name *

Primary contact email *

Banking

The business bank account for this location. You'll find both numbers at the bottom of a check.

PendingEnhanced encryption and access controls for banking information are still being set up.

Bank routing number *

Nine digits.

Bank account number *

Confirm account number *

Review and submit

Take a moment to check your answers. You can scroll back up to make changes before you submit.

Important disclosures

Patient Capital is not a bank and does not originate loans. Loans are originated by lending partners, who make all credit decisions. All financing is subject to credit approval and eligibility; terms vary by lender and patient, and not all applicants qualify. Loans are issued by Happen Bank, N.A., Equal Housing Lender, NMLS ID 167439.

By providing your email address, you agree that we may send promotional information about our products and services to you via email. You may opt out any time.

By providing your telephone number, you agree that we may contact you via telephone with promotional information about our products and services. This includes contacting you using prerecorded or artificial voice message calls, text messages, and calls made by an automatic telephone dialing system. Standard data and message rates will apply. You understand your consent to receive promotional information via telephone is not required to enter into any agreement with Happen Bank. You may opt out at any time.

Patient Capital uses the information on this form to register your location and verify your business, and shares it with Happen Bank to prepare your Participating Provider Agreement. Please don’t include anything beyond what the form asks for. Read our Privacy Policy and Terms & Conditions.

Takes a moment. Please don't close this page.

Share your location's information

Have these ready before you begin

Location type

Business information

Location

Owner

Office contact

Office address

Corporate headquarters

Primary contact

Banking

Review and submit

Important disclosures

Thank you. We received your information.

What you submitted