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  • Health Smart will pay your preferred provider directly.

Provider Information


Do you already know which healthcare provider or merchant you require funds for?


Please enter your provider's details below.



If you do not yet have a chosen provider, PayBright will be happy to recommend one of our many provider partners in your area. Please tell us a bit more about what you are looking for.


Applicant Information


  • Please use the Address Lookup above to find your address. Your address will be automatically entered into the form below.

  • (mm/dd/yyyy)

Personal Information


Previous Address:
  • Please use the Address Lookup above to find your address. Your address will be automatically entered into the form below.

    • Job Start Date:
  • Job Start Date:
  • Job End Date:

Joint Applicant Information


  • Address : Same as Principal Applicant
  • (mm/dd/yyyy)

Joint Applicant Personal Information


    • Job Start Date:
  • Job Start Date:
  • Job End Date: