Medical Records Collection Form

Participating providers may use this form to submit Medical Records for HEDIS and MRA.

Use the scroll down menu to select the appropriate categorization.

PC # *

Member DRS # *

Date of Service *

Record Type *

Upload Documents Here *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

The file formats you can upload are .tiff, .jpg, .png, and .pdf. If attachment is over 30MB, please split the file to conform to size limit.

Captcha Security Question *