Credentialing/Third Party Administrator Claims History Request for a Physician Insured by CRICO

Please complete this form. * = required field

Requirements for Claims History Requests

Degree not on list?
Enter yours here.

Delivery & Support Information

Enter the two letter state code. If you have the contact's email, please include it in "Note to Underwriting."

Confirmation and Follow-Up

By checking the box, you are confirming that you have the necessary authorization to obtain a claims history on behalf of a CRICO-insured provider. Further, you acknowledge that you have verified the recipient email address above.