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Please acknowledge that you understand Medcom will only review/process requests that have been successfully completed. You will automatically receive a confirmation email with a reference number and copy of the submitted data with successful completion of the form. Medcom Benefit Solutions will not access, review, or process any incomplete forms. If you do not receive a confirmation email, please reach out to our team for assistance.
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I have read and understand the above
Premium Billing Online Access Request
Employer Name:
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Requested by:
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Employer
Broker
Name of Person Making Request:
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Email Address of Person Making Request:
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Add or Remove Access?
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Add Access
Remove Access
Add & Remove Access
How Many People Add Portal Access?
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How Many People Need Portal Access Removed?
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What system are you requesting access to?
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myRSC
Summit
Save & Return
Use an account to return to saved work.
Log in