Extended Care Hospital - ROH - Affiliation Portal
Providers for Regional One Health
Extended Care Hospital - Regional One Health
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Requester Name
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Requester Title
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Requester Organization
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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 the Extended Care Hospital at Regional One Health 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 Regional One Health 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 the Extended Care Hospital - Regional One Health.
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Provider Last Name
Provider First Name
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Requester Title
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