Mills Peninsula Health Services - Welcome to the Provider Affiliation Verification System.

By clicking “Yes” below, you certify that the following statements are true:

1. The Practitioner for whom you have requested a verification inquiry response has signed an Authorization and Release consenting to the sharing of information between your entity and any Medical Staff of which the Practitioner is and/or was a member and/or applicant.
2. The entity, on behalf of which you are requesting a verification inquiry response, is a peer review body within the meaning of California Business and Professions Code Section 805.
3. The information provided to you in response to the verification inquiry will be used for the sole purpose of assisting with your evaluation of the Practitioner’s qualifications and fitness for medical practice.
4. You will maintain the confidentiality of the information provided in response to the verification inquiry, as contemplated by California Evidence Code Section 1157.

*Provider Last Name
Provider First Name
*Provider Birthdate
*Requester Name
*Title
*Organization
Address
City, State, Zip
*Phone