MetroHealth Legal-Risk Insurance Request Form

This is a form to request the following: (1) Verification of Provider Malpractice Insurance and/or claims history; and (2) Certificates of Insurance.

First name
Please enter your first name.
Last name
Please enter your last name.
E-mail address
Please enter your email address.
(email format: you@example.com)
Phone number
Please enter your phone number.
(phone number format: 1234567890)
Nature of Request
Please select a nature of request.
Name of Requestor
Please enter the requestor's name.
(The person designated to receive certificates per request)
Requestor Role
Please enter the requestor's role.
Requestor Email Address
Please enter the requestor's email address.
Name of Vendor
Please enter the vendor's name.
Name of Contract
Please enter the contract name.
Contract Dates
Please enter the contract dates.
New Certificate or Renewal Certificate
Please select the kind of certificate.
Please upload a copy of previous certificate.(Required)
File(s)
file is required.
Name of Provider
Please enter the provider's name.
Department
Please enter a department.
Please enter the credential(MD, DO, NP, PA, CNP, etc)
Please enter the Credential.
Title/ Position
Please enter the Title/ Position.
Dates of Employment
Please enter the employment dates.
(If intermittent, provide all dates of service)


Please upload a copy of the Release of Authorization signed by the provider.(Required)
File(s)
file is required.
* A Claims History/Loss Run will automatically be provided. *
Do you require the verification to be sent to someone else?
Please select an answer.
Please provide the required verification contact information:
Name
Please provide a name.
Address
Please provide an address.
Phone
Please provide a phone number.
Email
Please provide an email address.
Do you wish to be copied on this verification?
Please select an answer.