Verification Lookup Portal
Providers for Connecticut Children's Medical Center
Connecticut Childrens Medical Center
Provider Last Name
Last name is required.
Provider First Name
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Provider Birthdate
Birthdate is required.
Provider Full SSN
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Provider NPI
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Required Information
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Requester Name
Name is required.
Requester Title
Title is required.
Requester Organization
Organization is required.
Requester Address
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Requester City, State, Zip
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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 informaton. Such signed release and immunity holds harmless and indemnifies Connecticut Children's Medical Center 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 Connecticut Children's Medical Center 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 Connecticut Children's Medical Center.
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Please Enter the Following Information:
Facility
Provider Last Name
Provider Birthdate
Requester Name
Requester Title
Requester Organization
Requester Phone
Requester Email