Verification Lookup Portal
Providers for KOS Services, LLC
Dental Dreams
Provider Last Name
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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
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Requester Title
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Requester Organization
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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 **ENTER CLIENT NAME** 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 **ENTER CLIENT NAME** 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 **ENTER CLIENT NAME**.
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Please Enter the Following Information:
Facility
Provider Last Name
Provider First Name
Provider Birthdate
Provider NPI
Requester Name
Requester Title
Requester Organization
Requester Address
Requester City, State, Zip
Requester Phone
Requester Fax
Requester Email