Physician Credentials Verfication Service Order Form  - $469 / Physician

Fees charged by Verifying Sources are charged in addition to MedLicense.com fee of $469

To begin the process, please enter your information below:  
Hospital/Practice Name:
Hospital/Practice Contact Name & Title:
Hospital/Practice Mailing Address:
Hospital/Practice Phone Number:
Hospital/Practice Email:
Physician's Full Name:
Physician's Date of Birth:
Physician's Place of Birth:
Physician's Social Security Number:
Degree Type (MD, DO, PA, NP, DDS, DMB, etc):
Medical School Name and Location:
Medical School Dates of Attendance & Graduation Date:
ECFMG Number and Issue Date (if applicable):
States where the Physician has been licensed Past and Present:
Board Certification:
Year First Certified and Re-Certified:
What License Examination did he/she Take?
Please provide any information about potential negative information: (i.e. Probations, Leave of Absences, Board Actions, Probations, Arrests, Disciplinary Actions, Suspensions)
Select Credentials to be Verified: State Licenses (past/present)
Exam Scores
College Transcripts (undergrad)
Medical School Transcripts
Medical School Dean's Letter
Internship/Residency/Fellowship Verification Letter
Employment
Privileges
Malpractice
AMA/AOA Profile
FSMB Board Action Report
NPDB-HIPDB Report
Physician References
Board Certification
Medical Society Membership
Criminal Background Check
Do you wish to use Fedex for All Shipments? ($20.00 per Verification)
Credit Card Number:
Credit Card Expiration Date:
Credit Card 3-4 digit Pin # (on Back of the Card - VISA, MC, or Discover - on Front for AMEX)
Name on the Credit Card:
Billing Address of the Credit Card: