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Patients - Apply Now

 

 

Before completing the application, please take a moment to review the helpful hints listed below:

 

1)  Make sure that you complete the credit application form in its entirety.  Partially completed application forms may result in decline or delay for financing.

 

2)  If a co-applicant will be required for financing, please complete the co-applicant section of the application.

 

3)  List the name of your provider or your provider number.

 

4)  Please ensure that you have reviewed and understand the Terms & Conditions before submitting your application to Health One Financial, LLC.  Please print a copy of the application for your personal records.

 

 
 
 
 
 

 

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To request an emailed copy of our credit application, please complete the following form: 

 

       
Name:   Comments:
Phone Number:  --  
Email:      
Provider ID Number:      
(or Surgeon's Name)    
     

 

 

  Please fax your completed application form to Health One Financial at 888-748-3625.


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