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    Availity Identity Verification Form

    Uploaded by

    Shankar Ganesh Jayaraman
    This identity verification form requires the user to print the form, have their signature notarized with a valid government ID, and mail the original notarized form to Availity for identity verification. Once completed, this process will provide the user access to additional secured services on the Availity platform. The form collects the user's personal information, Availity user ID, notary information, and signatures for verification purposes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Availity Identity Verification Form

    Uploaded by

    Shankar Ganesh Jayaraman
    347 views1 page
    This identity verification form requires the user to print the form, have their signature notarized with a valid government ID, and mail the original notarized form to Availity for identity verification. Once completed, this process will provide the user access to additional secured services on the Availity platform. The form collects the user's personal information, Availity user ID, notary information, and signatures for verification purposes.

    Original Description:

    Availity Identity Verification Form

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    © © All Rights Reserved

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    This identity verification form requires the user to print the form, have their signature notarized with a valid government ID, and mail the original notarized form to Availity for identity verification. Once completed, this process will provide the user access to additional secured services on the Availity platform. The form collects the user's personal information, Availity user ID, notary information, and signatures for verification purposes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    347 views1 page

    Availity Identity Verification Form

    Uploaded by

    Shankar Ganesh Jayaraman
    This identity verification form requires the user to print the form, have their signature notarized with a valid government ID, and mail the original notarized form to Availity for identity verification. Once completed, this process will provide the user access to additional secured services on the Availity platform. The form collects the user's personal information, Availity user ID, notary information, and signatures for verification purposes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    v2.2 Rev.

    1/8/2021

    Identity Verification Form


    Availity takes your privacy very seriously. One more step is required to validate your identity. Once completed, this step will provide you with
    access to additional, secured services.

    To complete your final step:


    Print this form and present it, along with a valid government-issued ID, to a notary public and have your signature notarized. Complete the
    User Information section and follow all user instructions. You will be notified by email when the form has been processed.

    USER INFORMATION USER INSTRUCTIONS


    Legal First Name Date of Birth (MM/DD/YYYY)
    In this section, the user must
    SivarajKumar 05/03/1985 complete all three steps:
    Legal Last Name Availity User ID 1. Enter your personal information
    in the fields.
    Krishnamoothy sivarajk
    State (if applicable) Country 2. Enter the Availity user ID that is
    used with your Availity account.
    3. Sign your name and enter
    Signature Date (MM/DD/YYYY) today’s date.

    NOTARY INFORMATION AND NOTARY SIGNATURES USER INSTRUCTIONS


    This section is to be completed by the notary public In this section, the user must
    Notary State (if applicable) Notary Country complete both steps:
    1. Present one form of a valid
    government-issued ID to the
    I hereby certify that on this day of , 20 notary public.
    2. Mail the completed, original
    notarized form to the following
    (write the name of the above referenced person as it appears on their government-issued ID) address:
    personally appeared before me to sign or acknowledge this instrument. Attn: Availity ID Verification
    10004 N. Dale Mabry Hwy
    Valid Government-Issued ID (used as proof of identity; select one that applies) Suite 106
    Driver’s License or Govt Identification Card Tampa, FL 33618
    Social Security Card State: ______________
    Passport
    Birth Certificate Country: ____________
    Military ID Card
    Other (please specify) _____________________

    Notary First Name Notary Last Name

    Notary Signature

    Notary Commission Expires Notary Seal

    Notary Commission #

    Print
    Print Form Clear
    Clear Form

    THIS DOCUMENT IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this document may
    contain confidential health information that is legally privileged. This information is intended only for the use of the individuals or entities listed
    above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the
    contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and
    arrange for the return or destruction of these documents.

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