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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
COBRA Online Access Request
Employer Name:
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Requested by:
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Employer
Broker
Requested by Name:
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Email Address of Requesting Individual:
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Add or Remove Access?
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Add Access
Remove Access
Add & Remove Access
How Many People Need Portal Access?
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How Many People Need Portal Access Removed?
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Save & Return
Use an account to return to saved work.
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