* Facility  
 
*Required Fields
 *Provider Last Name  
   Provider First Name  
 *Provider NPI   
 *Requestor Name  
 *Requestor Title  
 *Requestor Organization  
 *Requestor Address  
 *Requestor City, State & Zip  
  
  

I agree and acknowledge that I possess a signed release and immunity statement signed by the practitioner for which I am obtaining verification information from Ephraim McDowell Health, Inc., Ephraim McDowell Regional Medical Center, Inc., Ephraim McDowell Fort Logan Hospital, Ephraim McDowell Health Resource, Inc. and their related and affiliated entities ("EMH"). Such signed release and immunity holds harmless and indemnifies EMH and individuals providing information pursuant to this request, its medical staff, board of directors and each of their respective members and designees, the administration, any related or affiliated entities, and their directors, officers, employees, attorneys, representatives and agents from any and all claims, demands or actions with respect to all acts or omissions, including without limitation, communications, reports, recommendations, or disclosures performed or made in connection with the request for the release of information pertaining to the practitioner's hospital or clinic affiliation with EMH.