Credentialing/Third Party Administrator Claims History Request for a Physician No Longer Insured by CRICO

Please complete this form. Upon submission, you will be directed to the payment page where you can remit the $25 claims history processing fee using PayPal.
* = required field

Requirements for Claims History Requests

Degree not on list?
Enter yours here.

Please add requests for others to this box. Include the information above: name, title, employer, & SSN digits with each request separated by semicolons. Be sure to include a signed release form for each individual.

Delivery & Support Information

To send to another person, enter the email address and name in "Note to Underwriting" below.

If you have the contact's email, please include it in "Note to Underwriting."

Confirmation and Follow-Up

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