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https://geisinger.medhub.com/functions/verifications/index.mh
Submission: On March 05 via manual from US — Scanned from DE
Submission: On March 05 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST index.mh
<form action="index.mh" method="POST" enctype="multipart/form-data" id="request_form">
<input type="hidden" name="action" value="verification_request">
<div style="overflow:auto; width:100%;">
<div style="float:left;border:1px solid #DDDDDD;background-color:#EFEFEF;padding:12px;">
<table cellspacing="4" cellpadding="3" border="0">
<!-- RESIDENT INFO -->
<tbody>
<tr>
<td colspan="2" class="section_header">
<h3>Resident/Fellow Information</h3>
</td>
</tr>
<tr>
<td>Trainee Name*: </td>
<td>
<table cellspacing="0" cellpadding="0" border="0">
<tbody>
<tr>
<td><span class="small">First*:</span><br><input type="text" name="request_resident_firstname" style="width:170px;" required=""><br clear="all/"></td>
<td style="padding-left:5px;"><span class="small">Middle:</span><br><input type="text" name="request_resident_middle" style="width:30px;"></td>
<td style="padding-left:5px;"><span class="small">Last*:</span><br><input type="text" name="request_resident_lastname" style="width:174px;" required=""></td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td>Trainee Aliases: </td>
<td><input type="text" name="request_resident_aliases" style="width:400px;"></td>
</tr>
<tr>
<td>Approx. Graduation Year: </td>
<td><input type="text" name="request_resident_year" style="width:100px;"></td>
</tr>
<tr>
<td>Residency/Fellowship Program: </td>
<td><input type="text" name="request_resident_specialty" style="width:400px;"></td>
</tr>
<!-- REQUESTOR INFO -->
<tr>
<td><br></td>
</tr>
<tr>
<td colspan="2" class="section_header">
<h3>Your Contact Information</h3>
</td>
</tr>
<tr>
<td>Your Name*: </td>
<td><input type="text" name="recipient_name" style="width:400px;" required=""></td>
</tr>
<tr>
<td>Company/Institution*: </td>
<td><input type="text" name="recipient_company" style="width:400px;" required=""></td>
</tr>
<tr>
<td>Your Email Address*: </td>
<td><input type="text" name="recipient_email" style="width:400px;" required=""></td>
</tr>
<tr>
<td>Phone Number: </td>
<td><input type="text" name="recipient_phone" style="width:400px;"></td>
</tr>
<tr>
<td>Fax Number: </td>
<td><input type="text" name="recipient_fax" style="width:400px;"></td>
</tr>
<tr>
<td valign="top" style="padding-top:6px;">Address: </td>
<td>
<table cellspacing="0" cellpadding="0" border="0">
<tbody>
<tr>
<td colspan="3">
<span class="small">Street - Line 1*:</span><br>
<input type="text" name="address_line1" style="width:400px;" required=""><br>
<span class="small">Street - Line 2:</span><br>
<input type="text" name="address_line2" style="width:400px;"><br>
<span class="small">Street - Line 3:</span><br>
<input type="text" name="address_line3" style="width:400px;"><br>
<span class="small">Street - Line 4:</span><br>
<input type="text" name="address_line4" style="width:400px;"><br>
</td>
</tr>
<tr>
<td>
<span class="small">City*:</span><br>
<input type="text" name="address_city" style="width:200px;" required="">
</td>
<td>
<span class="small">State*:</span><br>
<input type="text" name="address_state" style="width:60px;" required="">
</td>
<td>
<span class="small">Zipcode*:</span><br>
<input type="text" name="address_zipcode" style="width:100px;" required="">
</td>
</tr>
<tr>
<td colspan="3">
<span class="small">Country*:</span><br>
<input type="text" name="address_country" style="width:400px;" value="United States" required="">
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<!-- FILE -->
<tr>
<td><br></td>
</tr>
<tr>
<td colspan="2" class="section_header">
<h3>Authority for Release <span style="color:#FF0000;">(Required for Processing)</span></h3>
</td>
</tr>
<tr>
<td>Scanned File: </td>
<td><input type="file" name="request_file" style="width:400px;" required=""></td>
</tr>
<!-- NOTES -->
<tr>
<td><br></td>
</tr>
<tr>
<td colspan="2" class="section_header">
<h3>Additional Comments/Notes</h3>
</td>
</tr>
<tr>
<td>Additional Notes: </td>
<td><textarea type="text" name="request_notes" style="width:400px;height:60px;"></textarea></td>
</tr>
<tr>
<td colspan="2">
<hr>
</td>
</tr>
<tr>
<td></td>
<td><input type="submit" value="Send Verification Request" class="button affect"></td>
</tr>
</tbody>
</table>
</div>
</div><br clear="all/">
<span class="small" style="color:#808080;">* required fields</span>
</form>Text Content
MedHub - RESIDENT/FELLOW VERIFICATION REQUEST Use this electronic form to request training verification for any physician in an accredited graduate medical education program, including interns, residents, and fellows that are currently training or have trained at Geisinger. * Please fill out all the required fields below. If you are requesting training verification for anyone that graduated prior to 2009 then please add their date of birth and the last 4 of their social security number in the additional notes. * You must provide a signed, uploaded copy of an industry-standard release and consent form. The Standard Authorization, Attestation and Release form from the requesting organization is acceptable. Please note that we will submit a standard verification letter for all trainees and we are unable to complete any additional forms requested by your organization. The verification letter link will be sent to the email address provided and a hard copy will not be provided unless specifically requested. If you are submitting a request for Medical Board Licensure then please upload the form to be completed AND the signed authorization/consent to release form. We are only able to complete verifications of podiatry training if the learner graduated in 2017 or after. Please submit requests for podiatry training completed prior to 2017 to CPME at https://www.cpme.org/Applications/Forms/FormDisplay.aspx?FormID=103527&preview=1#:~:text=The%20Council%20on%20Podiatric%20Medical,completion%20of%20clerkships%20or%20preceptorships If you have any questions or do not receive a response within 14 business days, please call 570-271-6404. RESIDENT/FELLOW INFORMATION Trainee Name*: First*: Middle: Last*: Trainee Aliases: Approx. Graduation Year: Residency/Fellowship Program: YOUR CONTACT INFORMATION Your Name*: Company/Institution*: Your Email Address*: Phone Number: Fax Number: Address: Street - Line 1*: Street - Line 2: Street - Line 3: Street - Line 4: City*: State*: Zipcode*: Country*: AUTHORITY FOR RELEASE (REQUIRED FOR PROCESSING) Scanned File: ADDITIONAL COMMENTS/NOTES Additional Notes: -------------------------------------------------------------------------------- * required fields Privacy Settings We value your privacy and respect your preferences. We allow certain online advertising partners to collect information from our services (e.g., device identifiers and usage information) through technologies such as cookies and pixels to deliver ads that are more relevant to you and assist us with related analytics activities. This may be considered "selling" or "sharing/processing” for targeted online advertising under applicable law. To opt out of these activities, please click the button below. Please see our Privacy Policy for more information. -------------------------------------------------------------------------------- Your Privacy Choices Toggle this button to the left to opt out. -------------------------------------------------------------------------------- Cancel Save