*Required Fields
* Please choose a Facility  
 *Provider Last Name  
   Provider First Name  
 *Provider Birthdate   
 *Requester Name  
 *City, State & Zip  
Welcome to the Practitioner Affiliation Verification System.

By clicking ''yes'' below, you certify that the following statements are true:

1) The practitioner for whom you have requested a verification inquiry response has signed an Authorization and Release consenting to the sharing of information between your entity and any Medical Staff of which the Practitioner is and/or was a member, and/or held privileges, and/or was an applicant.
2) The entity, on behalf of which you are requesting a verification inquiry response, is a peer review body within the meaning of Oregon Revised Statutes (ORS) 41.675.
3) The information provided to you in response to the verification inquiry will be used for the sole purpose of assisting with your evaluation of the Practitioner's qualifications and fitness for medical practice.
4) You will maintain the confidentiality of the information provided in response to the verification inquiry, as outlined under ORS 41.675.
* Yes, I certify that the above statements are true.