Request a Provider's Certificate and Claims History

If requesting for yourself, please put in "Self."
It slows processing time if provider names do not match what is in UW Payroll systems. Please try to input the provider name as close as possible to what might be in UW Payroll. e.g. If the provider goes by J. Mary Doctor, but her real name is Jasmine Mary Doctor, please input Jasmine Mary Doctor.
Use Ctrl to select more than one option.
Is the provider still employed by UW?
While at UW, provider was a . . .
Enter e-mail of where you would like the certificate sent.
Documents Requested
Why are you requesting this certificate?
In order to release claims information, we require a signed claims release for each provider: Release Form The release form must explicitly give us (UW) consent to release the malpractice/professional liability claims history.
One file only.
2 MB limit.
Allowed types: tif, rtf, pdf, doc, docx, xls, xlsx.
If you have any other information that would help identify this provider if he/she has a common name.