Apply to Join | MedCost

Become a MedCost Network provider

Complete all fields. Missing information may delay processing.
All professional providers, facilities or ancillary providers must be credentialed and approved to participate in the MedCost Network before an effective date is assigned.
You cannot complete your application until your IRS Form W-9 has been emailed to us. Please download, complete, and email your W-9 form before continuing.
Steps to send your W-9 form:
- Download the W-9 Form and complete it in its entirety.
- Email the completed W-9 form to [email protected].
- Include the Practice Name exactly as it appears on your W-9 in the email subject line.

I have completed and emailed the W-9 form to [email protected]*

Practice Information

Practice Name (exactly as it appears on your W-9) *

Tax ID Number (EIN) *

(For security and privacy, enter an EIN only. Do not provide an SSN.)

Group NPI*

Is your practice telehealth only?

Select only if your practice delivers services exclusively via telehealth. If selected, your address will not be listed in the MedCost directory.

Main Practice Street Address

Street address only, no P.O. boxes. This will be listed in the MedCost directory unless you opted out above.

Address*

Address 2

City*

State*

ZIP*

Main Phone*

Main Fax*

Billing Address*

Street Address*

City*

State*

ZIP*

Billing Phone*

Billing Fax *

Practice Contact

Practice Contact Name*

Practice Contact Title*

Practice Contact Phone*

Practice Contact Fax*

Practice Contact Email*

Credentialing Contact

Credentialing Contact Name*

Credentialing Contact Title*

Credentialing Contact Phone*

Credentialing Contact Fax*

Credentialing Contact Email*

Credentialing Contact Mailing Address

Address*

Address 2

City*

State*

ZIP*

Provider Roster

Provider
Provider Name* Degree* For example: MD, LMCHA, LCSW, RD, NP Date of Birth* Type of Specialty* Practicing Primary, for example: LPC, LCMHA, Family Practice CAQH ID* Provider NPI* Hospitalist* Yes No List in MedCost Provider Directory? * Yes No

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Practice Information

Main Practice Street Address

Billing Address*

Practice Contact

Credentialing Contact

Credentialing Contact Mailing Address

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Looking For a Doctor or Facility?

HPI Acquires MedCost

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Become a MedCost Network provider

Practice Information

Main Practice Street Address

Billing Address*

Practice Contact

Credentialing Contact

Credentialing Contact Mailing Address

Provider Roster

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