Treasurer's Office Claims History Request Form

Treasurer's Office
Claims History Request Form

If the individual you are requesting a claims history for is/was at UMass Memorial Hospital or UMass Chan Medical School, those requests should be referred to Timothy Slowick at UMass Memorial, who manages that insurance policy and you should not submit your request here.

His email is Timothy.Slowick@umassmemorial.org. For any individuals who are/were at UMass Amherst, UMass Boston, UMass Dartmouth, or UMass Lowell, please continue to complete the request form below.

Information about the individual for whom you are requesting an insurance claims history

Name (required)

(first last)

This individual is or was a/an... (required)

Student ID (if known)

Employee ID (if known)

Which campus was this person a student or an employee on? (required)

Request information

Claims history from start date: (required)

Claims history to end date: (required)

What is the purpose of requesting this claims history? (required)

Do you have attachments? (required)

(Please provide any documentation that would be necessary to process your request. The faster we get what's needed to process your request, the faster it will be resolved.)

Attachment (required)

Additional attachment 1 (required)

Additional attachment 2 (required)

Additional attachment 3 (required)

Please provide your contact information so we can respond!

Name (required)

(first last)

Email (required)

(if you are a student, student-employee or an employee, use only your University of Massachusetts email address)

Campus (required)

Additional information (optional)