Request for Insurance Verification/Coverage History
If you have a coverage question unrelated to this form, you are directed to contact a policy specialist at 717-783-3770 x0 and an operator will assist you.
If you seek insurance carrier coverage history, please complete the following form. For assistance in completing this form, please direct calls to 717-783-3770 x291.
*REQUIRED FIELD
*Beginning Year Ending Year
Ex. 2006 2006
2006 2007
*Provider's Full Legal Name *Mcare License No. Ex.: MD-123456-x; HS-123456-x;
NC-123456-x; GP-123456-x
*Mailing Address Required even if requesting receipt via the "Alternative Method of Receipt"
If the address provided above is different from the mailing address you have on file with the PA Department of State, Bureau of Professional and Occupational Affairs (BPOA), we are unable to fulfill your request. If you need to update your address at BPOA, please contact them at 717-787-8503.
Alternative Method of Receipt - By entering a fax number in the block below you are requesting Mcare to fax the document on your behalf to the number entered below instead of mailing it. If the address provided above is different from the mailing address you have on file with the PA Department of State, Bureau of Professional and Occupational Affairs (BPOA), we are unable to fulfill your request.
Fax Number
Ex. xxx-xxx-xxx
I ATTEST that I am the undersigned and that I am duly authorized to make this request. I further ATTEST that the statements contained herein are true and correct to the best of my knowledge and belief, and that any false statements are subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities.
Date of Request
*Signature of Provider Required
*Telphone Number Required
Ex. xxx-xxx-xxx
PRINT and Sign then FAX your Request Form to: 717-705-7342 ORMail to:
Office of Mcare
Coverage History Request
P.O. Box 12030
Harrisburg, PA 17108-2030
