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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

Identification Requirements for Claims History Request

Requirements for Claims History Requests
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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.
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Delivery & Support Information
To send to another person, enter the email address and name in "Note to Underwriting" below.
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Enter the name of your organization.
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Where should the information be sent?
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Enter the two letter state code.
If you have the contact's email, please include it in "Note to Underwriting."
Confirmation and Follow-Up
I acknowledge this statement to be true.
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.
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