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

Please complete this form. * = required field

Requirements for Claims History Requests

Delivery & Support Information

Confirmation and Follow-Up

By checking the box, you are confirming that you have the necessary authorization to obtain a claims history on behalf of a CRICO-insured provider. Further, you acknowledge that you have verified the recipient email address above.