Request: Insurance, Claim Hx Verification - Self-Insurance Programs Self-Insurance Programs

The below request form is available to all individuals/entities, internal or external, in need of an INSURANCE VERIFICATION and/or CLAIM HISTORY report specific to a 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, or if you are in need of a release to accompany your request, please see the “Release: Provider’s Release of Information” page on our website.

NOTE: Information requested will be sent to the requestor, via email, unless specifically requested to do otherwise in the Comments section. Also, requests are handled in the order received. Please allow up to 10 business days for processing.

Requestor Information

Name *

First

Last

Requesting Entity *

Email *

Phone #

Fax #

Request Type *

Medical 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.