Claim History Request

Our Underwriting department is here to assist you.

For 3rd-party credentialers or admins.

Requirements for Claims History Requests

Is this a bulk request? * Yes No

Clinician Information

Clinician First Name *

Clinician Last Name *

Clinician Title/Degree *

Clinician Title Other

National Provider Identifier (NPI) *

CRICO-member employer

Mass General Brigham does not directly employ clinicians. Please be more specific.

Is the clinician still employed by a CRICO-member institution? * Yes No

There is a $25 fee for your request. The payment link will appear in an email when you submit this form.

Clinician's Signed Release Form

Releases must be dated within the last 6 months.

Bulk Requests

Add up to 10 clinicians in a bulk request. SSN digits needed for physicians only.

Clinician name

Title/degree

Last 4 SSN digits

Release form

Clinician name

Clinicians title/degree

Last 4 SSN digits

Release form

Clinician name

Clinicians title/degree

Last 4 SSN digits

Release form

Clinician name

Clinicians title/degree

Last 4 SSN digits

Release form

Clinician name

Clinicians title/degree

Last 4 SSN digits

Release form

Add More Rows

Clinician name

Title/degree

Last 4 SSN digits

Release form

Clinician name

Title/degree

Last 4 SSN digits

Release form

Clinician name

Title/degree

Last 4 SSN digits

Release form

Clinician name

Title/degree

Last 4 SSN digits

Release form

Clinician name

Title/degree

Last 4 SSN digits

Release form

There is a $25 fee for each provider who is no longer covered by CRICO. The payment link will appear upon submitting this form.

Requester Information

Requester's Name *

Requester's Organization *

Requester's Email Address *

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.

Note to Underwriting

Need a release form? Use this one if you don't have your own.

Can’t Reach Us? Assistance for CRICO members with urgent questions or needs may be obtained through the on-call risk manager at your institution.

Claims/Suits: Contact the Claim Manager responsible for your institution or the Senior Vice President of Claims.

Confirmation of Coverage /Facesheets: CRICO-insured physicians needing access to your Confirmation of Coverage (Facesheet), log into your Physician Portal, or email our Underwriting staff or 617.450.8219.

CME Questions: Email Maggie Janes or call 617.4506828.

Media Requests: Email Missy Padoll or call 617.450.6841.

Other Inquiries: To reach someone at CRICO, call 617.450.5500. If you are a physician, identify yourself as such and the organization with which you are affiliated. You will be connected to the CRICO representative responsible for your organization.

Requirements for Claims History Requests

Clinician Information

Bulk Requests

Requester Information

Confirmation and Follow-Up

Need a release form? Use this one if you don't have your own.

About CRICO

CME Opportunities

Patient Safety & Claims