This article provides guidance on how to complete the Reimbursify Payments enrollment form.

To help ensure your application process is easy to complete in one session, please gather the necessary information (see below) before beginning. With this information at hand, you can complete your Reimbursify Payments application in about 5 minutes.

  • Company Information
    • Business Legal Name
    • Address (PO Boxes are not allowed)
    • Business Start Date
    • Tax-identification Number of the business (EIN)
    • Website address
    • Company Category
      • For most Reimbursify practices, "Medical Services and Health Practitioners (Not Elsewhere Classified)" is the best choice from the list of options.
    • Company Type
      • Association, Corporation, Financial Institution, LLC, Partnership, Sole-Proprietor, or Tax Exempt
  • Primary Owner Information
    • Address (PO Boxes are not allowed)
    • Phone Number
    • SSN (Must be entered)
    • Photo of your current driver's license
    • Ownership *
      • If there are members that own 25% or more of the organization you will need to provide their information on via the application
  • Banking Information
    • Account Number 
    • Routing Number
    • A voided check (click here for other acceptable documents)
    • Name on Account
    • Annual Volume
    • Average Fee Amount (should not exceed High Fee Amount)
    • High Fee Amount (should not exceed Annual Volume)

Once the application is signed and submitted, please unlock your Experian credit for 72-hours so that our Underwriters can do a soft credit pull before approving your application.