Payment Services for
Healthcare Professionals

DOCPAYFreedom Enrollment Page

Looks great to me. Sign me up!

Note- This form is used to record the information required for your enrollment in the DOCPAY Freedom program. You should receive an enrollment packet by email within the next business day. For your convenience the forms will already have your information inserted. All you will need to do is print the documents, make any changes that are needed, sign at the indicated locations and either scan and email the agreement to info@docpay.com OR fax the forms to DOCPAY. Per federal regulations, you will also need to fax or email a copy of the practice owner's drivers license, a voided check from the account that funds should be deposited into and a copy of your business license.


I want to enroll with the following services:

 DOCPAYFreedom program ($29.95 per month) - Includes:
       - DOCPAYFreedom “No Fee” card processing service
       - DOCPAYplus Automatic Recurring Payment Plan service (no additional charge). Create standard recurring payments using ACH, Credit or Debit Cards (MasterCard, VISA, Discover and American Express) or Guaranteed recurring card payments using MasterCard or VISA credit cards

 The DOCPAYFreedom Bundle ($44.95 per month) - Includes:
       - DOCPAYFreedom “No Fee” card processing service
       - DOCPAYplus Automatic Recurring Payment Plans
       - ConfiCheck Bank Account Verification Service
       - DOCPAYonline Payments


My Information:
Practice Name: Contact Name:
Address Line 1: Address Line 2:
City: State:  Zip Code: - 
Telephone: Fax:
Email address: Web Site:
Type of Practice: Name of Owner of Practice:
How did you hear about us? Federal Tax ID:
Bank Name: Bank Location
(City, State):
Bank Routing Number
(9 digits):
Bank Account Number:
Send Reports By:  Fax      Email
Comments or Questions: