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Med Advantage Information Request Form

Request for Credentialing/Proposal Information In order for us to provide you with an online proposal, please complete the following questionnaire and "submit" to Med Advantage. If you wish to request a proposal without completing this online questionnaire, please email your request to sales@med-advantage.com.
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Type of Request

Company / Organization

First Name (Required)

Last Name (Required)

Title

Street Address

City

State/Province

Zip

Phone (Required)

Fax

Email (Required)

Type of Organization (Select all that apply)

Type of Service Requested (Select all that apply)

Type of Practitioners to be Credentialed / Recredentialed (Select all that apply)

Number of Practitioners to be Credentialed / Recredentialed

Type of Credentialing Needed (Select all that apply)

Please send information / proposal to contact person above by (Select all that apply)

Special Circumstances or Deadlines

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HMO
PPO
MCO
BHO
IPA
Hospital
Other (Please specify below)