Request Claims History
Request Claims History
Request Type
Purpose *
Individual Physician Claims History/Coverage Verification
Group Claims History Report
Requestor Information
Name *
Affiliation *
(Name of the organization requesting information
)
Email (To) *
Email (CC)
Phone *
Insured Information
First Name *
Middle Name
Last Name *
Suffix
NPI Number (if known)
Client ID (if known)
Policy Number *
Policyholder Name *
Policy State *
AL
AZ
CO
CT
DC
DE
FL
GA
IN
KS
KY
LA
MA
MD
MI
MO
NC
NH
NJ
NV
OH
OK
OR
PA
RI
SC
TN
VA
VT
WA
WV
Attach a Release Form For Your Request
If you do not have a standard release form, download this
sample form
.
File Upload *
Select File
View File
Accepted file types: pdf, Max. file size: 50 MB.