If you would like to join the MedCost Preferred PPO network, please complete the form below. MedCost will determine if there is a need for network providers of your specialty within your geographic area and will send a written response within 15-20 business days. *Indicates required field

Contact Name*
Contact Phone Number*
Contact Email Address
Practice or Facility Name*
Physical Street Address*
City, State, Zip*
Mailing Address (if different)
City, State, Zip (if different)
Tax ID*
Group NPI*
List the Provider Name, Specialty, Individual NPI, and CAQH ID (if applicable) for all Providers in Practice*