Cdr request form 2025

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The document is a CDR & PCSR Request Form for submitting requests for various healthcare reports, including Claim Detail Reports (CDR) and Paid Claim Summary Reports (PCSR). It outlines the necessary requestor information, delivery methods, report types with associated costs, order details, payment instructions, and validation requirements. The form must be completed and submitted to Xerox for processing.

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Click ‘Get Form’ to open the CDR request form in the editor.
Begin by filling out the 'Requestor Information' section. Enter your Provider/Facility Name, Address, Requestor Name, Date Requested, Phone, and E-Mail.
In the 'Delivery Method' section, select whether you prefer electronic delivery via Xerox Secure Web and indicate if you agree to the $30.00 shipping fee.
Next, choose your desired report type under 'Report Type & Cost Information'. Options include 1 YR Claim Detail Report (CDR) for $300.00, 1 YR Paid Claim Summary Report (PCSR) for $400.00, or a special Ad Hoc Report for $500.00.
Fill out the 'Order Information' section by providing your NPI Number or Legacy Number, Service Date, Paid Date, Claim Types, and Adjudication Status as required.
Finally, review the 'Payment Information' section where Xerox will notify you of total charges after validation. Ensure to remit payment to the specified address and include your memo line details.

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