Start an Application For Medical Financing | 855-503-1800

General Information

Service Type *

Amount Requested *

Between $1,000 and $35,000

Applicant

Person Receiving Services MUST be listed as the applicant if 18 years of age or older. A 2nd applicant may be added later in the application.

First Name *		Last Name *		Is this the Person Receiving Services? Yes No *
Is Person Receiving Services under 18 years of age? * Yes No				Name of Person Receiving Services *

Date of Birth *

Social Security Number *

We use 128 bit SSL protection and additional encryption to keep your information safe.

Email *

Please enter the applicant's correct personal email address to avoid delays with processing

Cell Phone Number *

(

)

At least one contact number required

Home Phone Number

(

)

Home

Address (no P.O. Boxes) *				City *
State *		Zip Code *		Monthly Mortgage or Rent Payment * $

Source of Personal Income

Employment Status *

2nd Applicant

Add a 2nd Applicant? *

If you feel you have non-qualifying credit for this pre-qualification, please add a 2nd Applicant. United Medical Credit may come back with a pre-approval for the 2nd Applicant if the first applicant does not qualify

About the 2nd Applicant

First Name *

Last Name *

Date of Birth *

Social Security Number *

We use 128 bit SSL protection and additional encryption to keep your information safe.

Email *

Please enter the 2nd Applicant's correct personal email address to avoid delays with processing

Cell Phone Number *

(

)

At least one contact number required

Home Phone Number

(

)

Where the 2nd Applicant Lives

Same address as applicant
Address (no P.O. Boxes) *		City *
State *	Zip Code *	Monthly Mortgage or Rent Payment * $

2nd Applicant Employment

Employment Status *

* Required field

Agreement

By clicking the 'Submit application' button, you are providing written consent under the Fair Credit Reporting Act for United Medical Credit and our lenders and partners with whom you are matched to obtain consumer reporting information from your credit profile or other information from one or more credit bureaus. You understand and agree that you are submitting an application for credit, and are consenting to the use of your consumer report information by United Medical Credit and our lenders and partners to conduct anti-fraud security checks and evaluate your application for credit. You understand that your application may be matched with multiple lenders, each of whom may obtain consumer report information from your credit profile.

I understand that if I am matched with Health Credit Services ("HCS"), by clicking the 'Submit application' button below, I am providing 'written instructions' to HCS under the Fair Credit Reporting Act authorizing HCS to obtain information from my personal credit profile or other information from Experian. I authorize HCS to obtain such information solely to prequalify me for credit options.

I have read, understand and accept the Privacy Policy, Terms, Additional Disclosures, Electronic Disclosure, Personal Credit Pull Authorization.

General Information

Search for your Provider...

Applicant

Home

Source of Personal Income

Employment Details

2nd Applicant

About the 2nd Applicant

Where the 2nd Applicant Lives

2nd Applicant Employment

2nd Applicant Employment Details

Agreement

Start an application

General Information

Search for your Provider...

Applicant

Home

Source of Personal Income

Employment Details

2nd Applicant

About the 2nd Applicant

Where the 2nd Applicant Lives

2nd Applicant Employment

2nd Applicant Employment Details

Agreement