Credit Card Processing Request Form

Please complete the following information to receive a no-obligation comparison or quote from the NCMIC Credit Card Processing Program.

Information marked with a * is required to submit your request.

Your Contact Information
  • (This Program is not available in Puerto Rico, Guam or Virgin Islands.)
  • (as xxx-xxx-xxxx)
  • (as xxx-xxx-xxxx)
  • Your e-mail address will never be shared or sold. It will be used to send you important notices.
Quote Information
It's easy to upload your most recent credit card processing statement for a free, no obligation comparison.
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.
No problem, although you won't be eligible for the challenge/offer, we'll still send you a quote.
  • Central Standard Time

NCMIC Finance Corporation and EHR software companies are separate entities, are not agents of one another, and have no authority to bind one another to financial or other contractual obligations. A three year contract is required to integrate NCMIC's Credit Card Processing Program with your EHR software. Early termination fees apply.