Affiliation Verification Portal
*Required Fields
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Provider Last Name
Provider First Name
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SSN (last four)
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Provider Birthdate
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Facility
Glen Cove Hospital
Huntington Hospital
Lenox Hill Hospital
Long Island Home
Long Island Jewish Forest Hills
Long Island Jewish Medical Center
Long Island Jewish Valley Stream
Mather Hospital
Northern Westchester Hospital
North Shore University Hospital
North Shore University Hospital Syosset
Peconic Bay Medical Center
Phelps Memorial Hospital Hospital
Plainview Hospital
South Shore University Hospital
Staten Island University Hospital
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Requester Name
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Title
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Organization
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Address
*
City, State Zip
** Note:When entering requester information, special characters such as '#' and '&' will be removed..