Hospital Affiliation Verification Lookup
Providers for Children's Minnesota
Children's Minnesota
Provider Last Name
Last name is required.
Provider First Name
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Provider NPI
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NPI number is invalid. Must be a ten-digit number.
Required Information
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Requester Name
Name is required.
Requester Title
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Requester Organization
Organization is required.
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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 NPI
Requester Name
Requester Title
Requester Organization