Provider Enrollment Form

To participate in the American Dental Finance Program please complete the form below. This includes your practice contact information as well as the practice’s routing and bank account numbers. When your patient has signed the loan documents, payment will be electronically transferred to your bank account within two business days. A representative will be in touch with you to review the process.

I acknowledge participation in the American Dental Finance Program and authorize U.S. Credit, Inc. to access the above bank account to deposit funds for procedures from my practice financed through the program. I agree to the terms of the program outlined in the American Dental Finance Program Guide, including the transaction fee agreed upon by my practice and U.S. Credit, Inc.

10 + 14 =

Program administered by U.S. Credit, Inc. with financing provided by third-party lenders. U.S. Credit, Inc. is not a broker or a lender. All lending subject to terms and conditions arranged directly between customer and such lender and are all subject to credit requirements and satisfactory completion of financing documents.