Medical Accounts Receivable Application

Fields marked with an * are required


General Information

Owner Information

Information About Your Business

Revenue Breakdown

Digital Signature

Electronic Signature Agreement.

By checking the "I agree to the Terms & Conditions" statement above, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By checking the "I agree to the Terms & Conditions" statement you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Octane Solution Group, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Octane Solution Group. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement. You further agree that each use of your E-Signature in obtaining a Octane Solution Group service constitutes your agreement to be bound by the terms and conditions of the Octane Solution Group Disclosures and Agreements as they exist on the date of your E-Signature.