User Registration External

Registration/Access Permission Form

This form is for users not directly employed by internal Global TPA to register with the HEDIS® web site. You must fill out ALL of the the items marked with a Red (*) from each section below before submitting a request.

Personal Information

First Name

Last Name

Confirm Email

Date of Birth

Gender

Address Information

Address 1

Address 2

City

State

Zip

Phone #1

Phone #2

Fax #

Access Request Detail

Access required for which Role?

Rights

Encounter Submission Read Only

Group Name

Group User: Select this option to request access to a particular Physician(s) HEDIS® member’s profile.

Which Providers access are you looking for?

Registration/Access Permission Form

Personal Information

Address Information

Company Information

Access Request Detail