MedCost Network Provider Charge Increase Information Request Web Form | MedCost

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Provider Details

Provider Name

Address

City

State

ZIP

List Any Additional Facilities Associated with Your Health System

Charge Increase Details

No, there has been no charge increase within the past 12 months

Yes, there has been or will be a charge increase

Percentage of charge increase

Effective Date

Managed Care Contact

First Name*

Last Name*

Email*

Phone*

CFO

First Name

Last Name

Email

Phone

CEO

First Name

Last Name

Email

Phone

Credentialing Contact

First Name

Last Name

Email

Phone

Additional Information

Provide any additional information.