Registration/Access Permission Form

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

Personal Information

Address Information

Company Information

Access Request Detail

Group User: Select this option to request access to all Physicians under a particular group.
Individual PCP User: Select this option to request access to a particular Physician(s) HEDIS® member’s profile.
 

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