Credentialing/Third Party Administrator Claims History Request for an Employee 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

Requirements for Claims History Requests

Degree not on list?
Enter yours here.

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 former CRICO-insured provider. Further, you acknowledge that you have verified the recipient email address above.