Provider Registration for Account

REQUEST ACCOUNT FOR PROVIDER WEB APPLICATIONS
Please complete the following form and then click the SUBMIT button. Registration is provided directly to the practice or hospital location. If you are a third party billing agent on behalf of the provider, please request that the practice or hospital office manager submit a request for registration. The office manager can then set up an account for billing staff.

(All fields are required unless specified otherwise)

Request Date	December 06 2023
Provider Name
Tax Number	If Federal Tax ID: -- Please choose format used OR (Not Both) to submit claims to MedCost. If Social Security #: -- --
Business/Office Manager First Name
Last Name
Main Address 1
Address 2	Optional.
City
State
Zip Code
Email Address
Confirm Email Address
Phone Number (Include Area Code)	999-999-9999 Format
Phone Extension	Optional.