Credentialing: Request Proof of Insurance or Loss Runs

Please complete the form below to submit a credentialing request. All credentialing requests require a signed authorization form from the provider prior to releasing their claims history report. Requests are processed in the order that they are received. More complete information will expedite the process.

Please note: You can also submit your request through email. The email for our credentialing department is credentialing@integrisgrp.com

*All fields are required

Requesting Company Name (if applicable)

Requestor Name*

Email*

Phone Number*

Provider/Practice Name*

Policy Number

Provider Title (if applicable)

Type of Request

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.