Application

Thank you for selecting Health One Financial as your patient financing company. To apply for financing, please complete the application below. Your application will be processed within 12 hours and a representative will contact you with your decision. Please note the following before completing the online application:

For faster approval, you have the option applying over the phone by contacting one of our customer service specialists at 888-748-3621.
Please remember to list your provider ID number (the provider ID number assigned to your provider by Health One) or your doctor's last name.
A minimum credit score of 630 is required for approval with Health One Financial. If you do not meet this minimum credit standard, you may choose to utilize a co-applicant. If you do elect to use a co-applicant to apply for a joint account, it is important to list the applicant with the strongest credit standing first on the application, regardless of who is the patient.

Check Your Credit Score

APPLICANT INFORMATION

*First Name		*Address
*Last Name		*City
*Social Security Number	--	*State
*Date of Birth	//	*Zip
*Preferred Contact Number	()-	*Provider Number
*Request Loan Amount

CO-APPLICANT INFORMATION (COMPLETE ONLY IF YOU ARE UTILIZING A CO-APPLICANT)

First Name		Address
Last Name		City
Social Security Number	--	State
Date of Birth	//	Zip
Preferred Contact Number	()-

FINANCIAL INFORMATION

*Current Employer		*Annual Income	$
*Employer Phone Number	()-	Co-App Annual Income	$
*How Long?	yearsmonths	Other Income	$
*Own or Rent?		Other Income Source
*Mortgage Payment	$/month
*How would you rate your credit?		Co-App credit standing?
*Checking Account

By completing the credit application form and submitting it, I agree to give Health One Financial and / or their lending companies, including, but not limited to, Banks, Finance Partners, Credit Card Issuers and other types of companies, written authorization to access your credit profile for review purposes. For consideration of the Health One Select Account, I understand that my credit information will be reviewed by Health One’s affiliated finance companies in order to assess the creditworthiness of this application. I understand that these finance companies will be solely responsible for issuing credit on this account. For consideration of the Health One Card, I understand that Elan Financial Services, as a creditor and issuer will rely on the information provided here in making its credit decision, and certify that such information is accurate and complete to the best of your knowledge. If Issuer opens an account based on this application, you will be individually liable if this is an individual account or individually and jointly accountable if this is a joint account for all authorized charges and for all fees referred to in the most recent Cardmember Agreement, which may be amended from time to time. You authorize Issuer, in determining your eligibility for credit, to verify your employment and income and all other information that you have provided, and obtain information about yourself, including your residence address, from other creditors, credit bureaus, employers, third parties, and federal and state records, including any state motor vehicle department, and waive any rights of confidentiality you hay have in that information under applicable to law. By selecting "SUBMIT", you authorize Issuer to provide Health One Financial with your credit decision and notify Health One Financial when you activate your card for the limited purpose of performing provider services. You also certify that you have read and understood both the disclosures and terms & conditions here and agree to the terms of this application. You understand that that you will be assessed a one time Program Fee of $49 or $4% of the procedure up to a maximum of $149, payable to Health One Financial for securing your financing. You understand this Program Fee will be billed to your Health One Account if you elect to finance your procedure through Health One Financial. No additional fees will be charged for future expenditures against your Health One account.

I have read the terms and conditions

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