Request: Insurance Verification and/or Claim History Report - Self-Insurance Programs_ Self-Insurance Programs

The below request form is available to all individuals/entities, internal or external, in need of a medical professional liability INSURANCE VERIFICATION and/or CLAIM HISTORY REPORT specific to a healthcare provider covered, or previously covered, by one of the following Self-Insurance Programs (SIP): University of Florida/UF Health Shands, Florida State University, University of Central Florida, Florida International University, and Florida Atlantic University.

All requests must include a release from the provider authorizing the SIP to disclose the requested detail. If already secured, you may attach the release to the request below. If you are in need of a release to accompany your request, please visit the “Release: Provider’s Release of Information” page on our website.

NOTE: Information requested will be sent to you, the requestor, via email unless you provide specific and different delivery instructions in the Comments section. Requests are handled as quickly as possible and in the order received. Please allow up to 10 business days for processing. If questions related to the process or status of your request, please call us at 352-273-7006.

Requestor Information

Name *

First

Last

Requesting Entity *

REQUIRED: Populate this field with the official name of the entity and/or individual that is to receive the documents.

Email *

REQUIRED: Populate this field with the email address for the entity and/or individual that is to receive the documents.

Phone #

NOT REQUIRED: Populate this field with your phone number.

FAX #

NOT REQUIRED: Populate this field with your facsimile number.

Request Type *

Healthcare Provider Information

Name *

First

Last

License Type

Status *

Involved Campus

Involved Campus *

Comments

Attachments: Please upload Release of Authorization and all other supporting documentation related to your request.

Click or drag files to this area to upload. You can upload up to 10 files.

Release of Authorization *

Confirm you have read the below and, if required, have attached a Release of Authorization to this request.

A Release of Authorization (ROA) must accompany this request unless you are 1) a healthcare provider currently covered by the SIP, and 2) the request is limited to an insurance certificate/verification, and 3) the documents are being sent directly to you. ALL OTHER other requests, including all requests for a Claim History Report, MUST include an ROA to be processed. ROA’s are available at the link provided in the opening paragraph of this page. Please do not submit a request without a required ROA.