0917-0009 Education Verification

DEPARTMENT OF HEALTH & HUMAN SERVICES Public Health Service

Indian Health Service

«FacilityName»

FacilityAddress

EDUCATION VERIFICATION

July 25, 2024

«RS_Name»

«RS_Address» «RS_Address2»

«RS_City», «RS_State» «RS_Zip»

PHONE:

«RS_Telephone»

FAX:

«RS_Fax»

RE:

«FormalNameWithDegree»

DOB: SSN:

«BirthDate» «SSN»

Dear Sir/Madam:

The practitioner listed above has applied for appointment to our facility.

Before we can process this application further, we require verification or completion of the following information regarding the applicant's training at your institution:

Type of Degree/Residency/Fellowship/Internship:

Inclusive Date of Attendance: To

Completed in good standing: Yes No

Was the practitioner ever subject to disciplinary proceedings or action at your facility? Yes* ___ No _____

Verified by:

Title: Date:

*If applicable, on a separate sheet of paper, please indicate any sanctions or disciplinary actions taken against

the practitioner during training, as well as any other pertinent information that would assist us in considering the applicant's appointment to our facility. A signed release is attached. «Image:File_REL»

Respectfully,

«UserFullName»

Medical Staff Professional

Medical Staff Office

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is [####-####]. This information collection is to be used in verifying an applicant’s credentials to meet agency policy, Centers for Medicare Conditions of Participation requirements, and accrediting body standards. The time required to complete this information collection is estimated to average less than 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is required to determine an applicant’s credentials to provide healthcare (IHS IHM 3-1.4 C. (1-2), CMS CoP §482.12(a)(6) and §482.22(c)(4) and [the nature and extent of confidentiality to be provided, if any ((the Privacy Act, 5 U.S.C. § 552; the Privacy Rule promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Part 160 and Subparts A and E of Part 164; the Indian Health Care Improvement Act, 25 U.S.C. § 1675; and the Confidentiality of Substance Use Disorder Patient Records regulations, 42 C.F.R. Part 2)]]. . If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: Indian Health Service, 5600 Fishers Lane, mailstop: 09E07, Rockville, MD 20857, Attention: Information Collections Clearance Officer