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

claimshistorywaiver

CRICO Contact Options

Claim History Request

Our Underwriting department is here to assist you.

* = required field

Requirements for Claims History Requests

Clinician Information

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

There is a $25 fee for your request. Click this link to submit payment to PayPal.

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.

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

Requester Information

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.