PROVIDER WEB
APPLICATIONS
REGISTRATION

Tuesday, November 12, 2019
7 : 56 AM


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 November 12 2019
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.
 
 


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