Please enter your information below. Then, click 'I Attest, Proceed to Search' to begin the verification search.
NOTE: The information you enter below is the information used on the verification letter produced for you by this application.
* Requestor Name
* Organization
* Address(1)
Address(2)
* City/State/Zip
Phone (optional)
EMail (optional)
*denotes required fields.
Attestation Statement: By utilizing this site, you attest that your organization is a healthcare entity that utilizes this information for protected peer review purposes only. Additionally, you are confirming that you have a a current release from the physician/practitioner on file granting you permission to obtain information regarding his/her affiliation and privileges from our facility.