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Preferred Medical Provider Application

Here is a “MUST” for Hospitals, MRI Centers & Orthopedics! Apply to become a Preferred MedChex Provider (“PMP”) and receive free patient referrals! There is nothing to lose because each patient referred to your facility has already been approved for funding. All PMP’s will be placed on our national list of providers and any applicants that apply with MedChex will be referred strictly to our Preferred MedChex Providers. There is no obligation to accept patients and you can be removed from the list at any time.

Complete the short application below and one of our representatives will be in touch with you within 48 hours.

Facility Name

Address City State Zip

Contact Person

Phone1 Fax

E-mail address Type of Facility

What percentage discount do you offer to cash paying customers?

When is the best time to contact you?

You will be contact shortly with a MedChex Member Number which you can refer to when contacting our company. Please direct all questions to (877) MEDCHEX
Medchex is not requiring any medical records from the Facility or Patient and the application remains HIPPA compliant.