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Credentialing/Third Party Administrator Claims History Request for an Employee 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

Identification Requirements for Claims History Request

Requirements for Claims History Requests
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i.e., CNM, CNP, PA, etc.
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i.e., MGH, MEEI
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MM/DD/YYYY
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MM/DD/YYYY
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Please add requests for others to this box. Include the information above: name, title, employer, & dates with each request separated by semicolons. Be sure to include a signed release form for each individual.
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Delivery & Support Information
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Enter the name of your organization.
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Where should this information be sent?
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Optional
Confirmation and Follow-Up
I acknowledge this statement to be true.
By checking the box, you are confirming that 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.
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Optional