Authorization and Release
I authorize The Premium Group, Inc. (“TPGI”) to retrieve from CAQH and to release to my Representative (identified in the logo above) and to both of their intermediaries and contracted-insurers and each of their respective employees, directors, officers, advisors, counsel and agents (individually or collectively “The Parties”), my entire provider data file from CAQH’s Universal Provider Datasource for the intended purpose of requesting insurance quotes and credentialing on my behalf. I further authorize The Parties to release my information as may be required for the intended purpose of this application. I further authorize my current insurer, and prior insurer(s) to release my history of claims that may have been made and/or are currently pending against me, if any, to The Parties. I specifically waive any and all written notice requirements from any entities or individuals who provide information based upon this Authorization and Release. I further acknowledge that each prospective insurer has its own criteria and my request for quotes and credentialing may be accepted or rejected by each independently.
I acknowledge that I have read the foregoing Authorization and Release and understand the terms. I understand and agree that by providing my signature below, this Authorization and Release will be transmitted to TPGI, for the stated purposes.
Please fill in all fields as they appear in your CAQH data (*Indicates field is required).
Date:
*Last Name:
*First Name:
Middle Initial:
*Provider Type:
CRNA
DC
DDS
DMD
DO
DPM
LPN
MD
MW
NMW
NP
OD
PA
RN
*Date of Birth:
*Email:
*Primary Office Address:
*City:
*State:
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
*Zip:
*Phone:
Social Security Number or NPI is required
Social Security Number:
NPI:
*Signature:
I authorize and release my information
Please direct questions or comments to
Questions@argusriskadvisors.com
.