Credentialing: Request Proof of Insurance or Loss Runs

Please complete the form below for all credentialing requests. Please note: All credentialing requests require signed authorization from the provider prior to the release of their claims history report.

*All fields are required

Requesting Company Name (if applicable)

Requestor Name*

Email*

Phone Number*

Provider/Practice Name*

Policy Number

Provider Title (if applicable)

Multiple choice

Proof of Insurance Loss Runs Other

Upload File

Please select a file

All credentialing requests require signed authorization from the provider prior to the release of their claims history report.

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