Payment Services for
Healthcare Professionals

DOCPAYplus Enrollment Page

Looks great to me. Sign me up!

Note- This form is used to record the information required for your enrollment. Once the information has been recorded, you will be taken to a page that displays the DOCPAYplus Client Service Agreement. For your convenience the form will already have your information inserted. All you will need to do is review the document, make any changes that are needed, upload a copy of the practice owner's drivers license and a voided check from the account DOCPAY will deposit funds into and then sign the agreement online. (We accept E-Signatures).

I want to enroll with the following services:
 DOCPAYplus Automatic Recurring Payments only ($0 per month- FREE)
 The DOCPAYplus Bundle ($15 per month)
     The Bundle includes:
       - DOCPAYplus Automatic Recurring Payments
       - 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: