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:
*Date of Birth:     *Email: 
*Primary Office Address: 
*City:     *State:     *Zip:  *Phone: 
Social Security Number or NPI is required
Social Security Number:    NPI:
*Signature: