HSR Claims Report Tool

  

This form is used to verify identity and determine eligibility of persons requesting access to the HSR Claims Report Tool website. Users of the site will be able to generate online reports based on sensitive claim data. This data MUST be safeguarded in accordance with strict HIPAA regulations. Submission of this form does NOT guarantee acceptance.

Registration Request Form
First Name
Last Name
Title
Company Name
Company Address
Company City
Company State, Zip Code ,
Email Address
Phone Number
Requested Access Level Single Policyholder (access to only 1 policy number)
Single Location / Campus (access to only 1 location or campus)
Agent/Broker (access to your policy accounts)
Insurance Company (access to all insurance company's policy numbers)
Applicable Insurance
Company Name, OR
Specific Policy Number(s)
Any Other
Information?
Privacy Agreement <== Click here to agree to the terms outlined in the
HSR ONLINE CLAIM REPORTS WEB PORTAL
PRIVACY OF PERSONAL HEALTH INFORMATION AGREEMENT

Please allow at least 3 business days for approval processing.