Verification Lookup Portal
Providers for GLOBAL MODE - Union Hospital
Union Hospital Clinton
Union Hospital Terre Haute
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 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 Union Health System 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 Union Health System 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 Union Health System.
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Please Enter the Following Information:
Facility
Provider Last Name
Requester Name
Requester Organization