Provider Affiliation Verification-ROPH
Providers for Global Mode
Rush Oak Park Hospital
Provider Last Name
Last name is required.
Provider First Name
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Provider Birthdate
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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
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Requester City, State, Zip
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Requester Phone
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Requester Fax
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Requester Email
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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 Rush Oak Park Hospital 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 Rush Oak Park Hospital 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 Rush Oak Park Hospital.
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Provider Last Name
Requester Name
Requester Organization