Identity Verification Form

Print this form, then notarize, scan and email to :  ma2@sdcim.com upon completion

IDENTITY VERIFICATION FOR INDIVIDUAL MEDICAL RECORDS AND PORTAL REQUESTS (Please include this Identity Verification Form with the SDCIM Universal Medcal Records/Portal Set Up Consent Form if your request is not in person, as it allows us to validate your consent form signature).

*Name:                                                                                                           *Date of birth:  

*Last 5 SSN:

*Email (current):

Email (which is on file with SDCIM as/if given previously):

*Phone (current):

*Phone (which is on file with SDCIM as/if given previously):               

*Address (current):

*Address (which is on file with SDCIM as/if given previously):

*REQUIRED (forms missing or not matching our records for required information will be deemed identity unverified as will illegible forms)

WE WILL USE CURRENT EMAIL, PHONE AND ADDRESS FOR CORRESPONDENCE ONCE IDENTITY IS VERIFIED.

DO NOT SIGN THIS STATEMENT UNTIL THE NOTARY DIRECTS YOU TO DO SO.

Patient Signature:                                                                                           Date signed:

 

Notary Public's Name (print):

 

Notary's Signature: Date Signed:

 

Expiration Date of Commission and SEAL