Payer Registration for Account

REQUEST ACCOUNT FOR PAYER WEB APPLICATIONS
Please complete the following form and then click the SUBMIT button. Registration is provided directly to the authorized user. The authorized user can set up an account for staff.

(All fields are required unless specified otherwise)

Payer Web Services
MedCost LLC - Copyright 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009.

Request Date	October 14 2024
Payer Name
Authorized User 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.