Cdr request form: Fill out & sign online

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01. Edit your cdr request form online

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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 the Provider/Facility Name, Address, Requestor Name, Date Requested, Phone, and E-Mail. Ensure all fields are completed accurately for validation.
Select your preferred Delivery Method. Indicate whether you want an electronic delivery via Xerox Secure Web and if you agree to the $30.00 shipping fee by selecting 'Yes' or 'No'. If physical delivery is required, provide a Shipping Address.
In the Report Type & Cost Information section, choose the report type you need (CDR, PCSR, or Ad Hoc) and note their respective costs.
Complete the Order Information section by entering your NPI Number or Legacy Number, Service Date, Paid Date, Claim Types, and Adjudication Status as applicable.
Finally, review the Payment Information section. Note that Xerox will notify you of total charges after validation. Ensure to remit payment as instructed.

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