Malpractice Verification - Graduate Medical Education

For whom are you requesting verification?*

First Middle Last

Program Information

Please identify all programs trainee was part of:

Program 1*

Start Date of Program 1*

End Date of Program 1*

Additional programs?

One
Two

Program 2

Start Date of Program 2

End Date of Program 2

Program 3

Start Date of Program 3

End Date of Program 3

Requested Documentation

Please check which documents will need to be provided*

Basic Information
Coverage Verification
Claims History

Who is requesting the Verification?*

I am the trainee
I am an outside requestor

If you're from an outside organization upload the signed release.*

Max. file size: 29 MB.

Electronic Signature

By checking this box and typing my name above, I am electronically signing this form. This electronic signature authorizes the University of Virginia Medical Center to release the requested information*

I Agree

Send Verification to:

Name*

Address*

Street Address Address Line 2 City State ZIP Code

Email

Phone*

Fax

Method to receive Verifications*

Email*
Mail
Fax

*Email is the preferred method of communication.