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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

Physical Address (no P.O. Boxes) *

City *

State *

Zip Code *

Click here if your mailing address is different from your physical address

Current Residence Move in Date *

Housing Status *

Monthly Mortgage or Rent Payment *

Reference

Name of Reference *

Not living with you

Relationship to Reference *

Phone Number of Reference *

(

)

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 an offer listing the 2nd applicant as the Primary signer 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

Physical Address (no P.O. Boxes) *

City *

State *

Zip Code *

Current Residence Move in Date *

Housing Status *

Monthly Mortgage or Rent Payment *

2nd Applicant Employment

Employment Status *

2nd Applicant Reference

Name of Reference *

Relationship to Reference *

Phone Number of Reference *

(

)

* 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.

Due to lender policies the person who is receiving the services is required to be listed as the main applicant if 18 years of age or older. If you believe the person who is receiving the services has non-qualifying credit, an option to add a 2nd applicant is provided at the end of this application. Funding may be canceled or declined if the person receiving the services is over the age of 18 and is not on the application (if the person receiving the services is a minor, please list the minor's legal guardian as the primary applicant).

SMS Terms and Conditions for Application Alerts: The United Medical Credit SMS alert program sends text reminders regarding the status of an applicants application throughout the process. United Medical Credit is not responsible for any charges from a person's service provider that may result from us providing this service. It is the applicants responsibility to check with their individual carrier, as standard messaging and data rates may apply. United Medical Credit assumes no responsibility for charges incurred by our text messaging service.

I have read, understand and accept the Privacy Policy, Terms and Conditions, Additional Disclosures and Electronic Disclosure.

General Information

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Applicant

Home

Reference

Source of Personal Income

Employment Details

2nd Applicant

About the 2nd Applicant

Where the 2nd Applicant Lives

2nd Applicant Employment

2nd Applicant Employment Details

2nd Applicant Reference

Agreement

Start an application

General Information

Search for your Provider...

Applicant

Home

Reference

Source of Personal Income

Employment Details

2nd Applicant

About the 2nd Applicant

Where the 2nd Applicant Lives

2nd Applicant Employment

2nd Applicant Employment Details

2nd Applicant Reference

Agreement