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.