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Credentialing/Third Party Administrator Claims History Request for an Employee Insured by CRICO

Please complete this form. * = 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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Please add requests for others to this box. Include the information above: name, title, employer, & date 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 current CRICO-insured provider. Further, you acknowledge that you have verified the recipient email address above.
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Optional