Registration/Access Permission Form

This form is for users not directly employed by the Health Plan to register with the MRA/ 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 a particular Physician(s) HEDIS® member’s profile.
IPA User: Select this option to obtain access to all physicians under a particular IPA.
 

Optimum Healthcare | 5403 N. Church Ave. Tampa, FL 33614 | (813) 506-6127 Phone | (813) 506-6151 Fax | Copyright© 2019 | www.YourOptimumHealthCare.com