Credit Card Processing Express Request Application

Please complete the following information to receive a no-obligation comparison or quote from the NCMIC Credit Card Processing Program. Information is required unless noted as optional. When finished, click "Submit Request” at the bottom of the page.

All fields marked with * are required.

Your Contact Information

Doctor's First Name: *

Middle Initial (Optional):

Last Name: *

Practice Name: *

Practice Address: *

P.O. Box, Apt., Ste., etc. (Optional):

City: *

State: *

(This Program is not available in Puerto Rico, Guam or Virgin Islands.)

ZIP: *

Practice Phone: *

E-Mail: *

Profession: *

Quote Information

Do you currently accept credit cards? *

Yes No

Statement

It's easy to upload your most recent credit card processing statement for a free, no-obligation comparison.

Do you have your current statement? *

Yes, and I'd like to upload it No, I don't have it available

Upload

Important: Please scan all pages of your processing statement prior to uploading. If you're having trouble uploading, print this cover sheet and fax it.

Please attach your statement

No problem, we'll still send you a no-obligation quote.

What EHR software do you currently use? (Optional)

What is the best time to contact you with questions? *

Central Standard Time

Request Your Quote

Express Request

Credit Card Processing Express Request Application

Questions

Request Your Quote