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. *

I have read and understand the above

COBRA Online Access Request

Employer Name: *

Requested by: *

Name of Person Making Request: *

Email Address of Person Making Request: *

Add or Remove Access? *

Add Access

Remove Access

Add & Remove Access

How Many People Add Portal Access? *

How Many People Need Portal Access Removed? *

What system are you requesting access to? *

myRSC

Summit

Save & Return

Use an account to return to saved work.