Test Form | Echelon Financial

Let's start by getting to know you ...
We need just a few details to get started.
Legal Entity Name (“Provider”) - please include LLC, Inc., PA., etc*
Fictitious Names (“D/B/As”) used by the Legal Entity - please list all
Phone*
Email*

Name of office contact processing payments
First Last
Phone
Email
Where are payments sent? (choose all that apply)*
- To Provider's Office
- To Provider's Bank Account
- To Lockbox
- Other
Name of Bank
Other
When are payments received? (check all that apply)*
- Daily
- Once a week
- Several times a month
- Monthly
Briefly describe how provider tracks payments*

Let's wrap this up!
By signing below, you represent that the above information is true, accurate and complete, and you acknowledge the information will be relied upon by Echelon Financial, LLC (“Echelon”). You also acknowledge that you may have been introduced to Echelon by a third party Introducing Agent or Partner. You acknowledge that this Introducing Agent or Partner is not an employee of Echelon and cannot bind or otherwise represent Echelon. Information conveyed to you from such Introducing Agent or Partner should not be relied upon without independent confirmation of same directly from Echelon. All information provided will be treated as confidential by Echelon in accordance with company policy, including, but not limited to, any applicable HIPAA and contractual obligations.
Name of responsible party*
First Last
Title*
Date Completed*
Date Format: DD slash MM slash YYYY

Let's start by getting to know you ...