providerportal.hfhs.org
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150.198.63.248
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URL:
https://providerportal.hfhs.org/psv/credverification.aspx
Submission: On May 05 via manual from US — Scanned from US
Submission: On May 05 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
Name: Form1 — POST ./credverification.aspx
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<script src="/PSV/WebResource.axd?d=7FWTjVe2lUqkvFWE4-VSk037vg_45T-whjJa41i8ro7BgYiC_beOaeXGzWl6viLCu_b9ZeYPgyFq9rHt8Ql_aCIMrY3xEUud3gTG0nYaIDA1&t=637823185837077270" type="text/javascript"></script>
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<img src="images/VerityStream-MSO_banner_1000.png" width="1000" usemap="#HomeMap" border="0">
<div id="spLabel" class="divhead" style="POSITION: relative; WIDTH: 652px; LEFT: 10px">
<table style="WIDTH: 645px" cellspacing="0" cellpadding="0" border="0">
<tbody>
<tr>
<td valign="top" align="right" width="100"></td>
<td valign="top" align="left" width="330"></td>
<td valign="top" align="left" width="195"></td>
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<tr>
<td style="HEIGHT: 44px" align="center" colspan="3">
<asp:label id="lblHeader1" runatresponse.writeserver"="" backcolor="Transparent" font-bold="True" font-size="X-Small" forecolor="Black" width="296px">Primary Source Verification Search</asp:label><br>
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</tr>
<tr>
<td align="center" colspan="3"><span id="lblInstr1" class="chklabelleft" style="height:40px;width:528px;Z-INDEX: 101; LEFT: 64px">
<p>We are <b><i>pleased</i></b> to provide this online primary source verification service to other hospitals, healthcare organizations and credentialing agents. It is not intended for use by patients or other visitors.</p>
</span></td>
</tr>
<tr>
<td align="center" colspan="3" height="70">
<table width="528px;">
<tbody>
<tr>
<td class="divInstruction">
<span id="lblInstructions" style="Z-INDEX: 102; width: 528px;">Enter all or part of the physician's last name, complete and submit the form. Results will appear and can be printed as a credentialing verification letter.</span>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td style="HEIGHT: 30px; width: 168px;" align="right"><span id="lblPractLastName" class="searchlabel" style="width:168px;">Practitioner Last Name: </span></td>
<td style="HEIGHT: 30px"><input name="txtPractitionerName" type="text" maxlength="250" id="txtPractitionerName" tabindex="10" class="inputfield" onchange="javascript:fnRemoveCH('txtPractitionerName')" style="width:272px;"></td>
<td style="HEIGHT: 123px" rowspan="4">
<div id="ValidationSummary1" class="errorbox" style="color:Red;height:40px;width:190px;display:none;">
</div>
</td>
</tr>
<tr id="trNPI">
<td align="right"><span id="lblNPI" class="searchlabel" style="width:168px;">Last 4 digits of NPI: </span></td>
<td>
<input name="txtNPI" type="text" maxlength="4" id="txtNPI" tabindex="19" class="inputfield" onchange="javascript:fnRemoveCH('txtNPI')" style="width:60px;">
</td>
</tr>
<tr>
<td style="HEIGHT: 30px" align="right"><span id="lblFacCode" class="searchlabel">Select facility: </span></td>
<td style="HEIGHT: 30px">
<select name="dbcFacCode" id="dbcFacCode" tabindex="20" style="width:264px;">
<option value=""></option>
<option value="HF-CH">Henry Ford Cottage Hospital</option>
<option value="HFH">Henry Ford Hospital</option>
<option value="JH">Henry Ford Jackson Hospital</option>
<option value="KW">Henry Ford Kingswood Hospital</option>
<option value="MH">Henry Ford Macomb Hospital - Clinton Township</option>
<option value="MH-WC">Henry Ford Macomb Hospital- Warren Campus</option>
<option value="SH">Henry Ford Specialty Hospital</option>
<option value="WBH">Henry Ford West Bloomfield Hospital</option>
<option value="WH">Henry Ford Wyandotte Hospital</option>
<option value="JHN">Jackson Health Network</option>
<option value="PCN">Physician Choice Network</option>
</select>
</td>
</tr>
<tr>
<td style="HEIGHT: 30px" align="right"><span id="lblYourName" class="searchlabel">Your Name: </span></td>
<td style="HEIGHT: 30px"><input name="txtYourName" type="text" maxlength="40" id="txtYourName" tabindex="25" class="inputfield" onchange="javascript:fnRemoveCH('txtYourName')" style="width:272px;"></td>
</tr>
<tr>
<td style="HEIGHT: 30px" align="right"><span id="lblYourTitle" class="searchlabel">Your Title: </span></td>
<td style="HEIGHT: 30px"><input name="txtYourTitle" type="text" maxlength="40" id="txtYourTitle" tabindex="30" class="inputfield" onchange="javascript:fnRemoveCH('txtYourTitle')" style="width:272px;"></td>
</tr>
<tr>
<td style="HEIGHT: 30px" align="right"><span id="lblYourOrg" class="searchlabel">Your Organization: </span></td>
<td style="HEIGHT: 30px"><input name="txtYourOrg" type="text" maxlength="40" id="txtYourOrg" tabindex="40" class="inputfield" onchange="javascript:fnRemoveCH('txtYourOrg')" style="width:272px;"></td>
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<tr>
<td></td>
<td><input type="submit" name="btnSubmit" value="Submit" onclick="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("btnSubmit", "", true, "", "", false, false))"
language="javascript" id="btnSubmit" tabindex="50" style="height:24px;">
</td>
<td></td>
</tr>
</tbody>
</table>
</div>
<div style="POSITION: relative; WIDTH: 658px; HEIGHT: 103px; TOP: 20px; LEFT: 10px">
<table cellspacing="0" border="0" id="dgPractList" style="width:656px;border-collapse:collapse;">
<tbody>
<tr class="xth" align="left">
<td>Verification Results</td>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
</tbody>
</table>
</div>
<span controltovalidate="dtBirthDate" errormessage="Birth Date is required." display="None" enabled="False" id="reqBirthDate" evaluationfunction="RequiredFieldValidatorEvaluateIsValid" initialvalue="" style="color:Red;display:none;"></span>
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<span controltovalidate="txtPractitionerName" errormessage="Last Name is required." display="None" enabled="False" id="reqLastName" evaluationfunction="RequiredFieldValidatorEvaluateIsValid" initialvalue="" style="color:Red;display:none;"></span>
<span controltovalidate="txtSSN" errormessage="SSN is required." display="None" enabled="False" id="reqSSN" evaluationfunction="RequiredFieldValidatorEvaluateIsValid" initialvalue="" style="color:Red;display:none;"></span>
<span controltovalidate="dtBirthDate" errormessage="Invalid date. Please enter a valid date." id="DOBvalidator" evaluationfunction="CustomValidatorEvaluateIsValid" style="color:Red;visibility:hidden;">Invalid date. Please enter a valid
date.</span>
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</script>
</form>Text Content
Primary Source Verification Search We are pleased to provide this online primary source verification service to other hospitals, healthcare organizations and credentialing agents. It is not intended for use by patients or other visitors. Enter all or part of the physician's last name, complete and submit the form. Results will appear and can be printed as a credentialing verification letter. Practitioner Last Name: Last 4 digits of NPI: Select facility: Henry Ford Cottage Hospital Henry Ford Hospital Henry Ford Jackson Hospital Henry Ford Kingswood Hospital Henry Ford Macomb Hospital - Clinton Township Henry Ford Macomb Hospital- Warren Campus Henry Ford Specialty Hospital Henry Ford West Bloomfield Hospital Henry Ford Wyandotte Hospital Jackson Health Network Physician Choice Network Your Name: Your Title: Your Organization: Verification Results Invalid date. Please enter a valid date.