Provider Affiliation Verification
Providers for Global Mode
Rush Copley Medical Center
Provider Last Name
Last name is required.
Provider First Name
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Provider Birthdate
Birthdate is required.
Provider NPI
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Required Information
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Requester Name
Name is required.
Requester Title
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Requester Organization
Organization is required.
Requester Address
Address is required.
Requester City, State, Zip
City, State, Zip is required.
Requester Phone
Phone is required.
Requester Fax
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Requester Email
Email is required.
I agree and acknowledge that I possess a signed release and immunity statement signed by the practitioner for which I am obtaining hospital verification information. Such signed release and immunity holds harmless and indemnifies Copley Memorial Hospital, Inc. and individuals providing information pursuant to this request, its medical staff, board of directors and each of their respective members and designees, the administration of such Copley Memorial Hospital, Inc. and its directors, officers, employees, representatives and agents, and each of them from any and all claims, demands or actions with respect to all acts, including without limitation, communications, reports, recommendations, or disclosures performed or made in connection with the request for the release of information pertaining to the practitioner's hospital affiliation with Copley Memorial Hospital, Inc..
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Facility
Provider Last Name
Provider Birthdate
Requester Name
Requester Organization
Requester Address
Requester City, State, Zip
Requester Phone
Requester Email