Request Verification

Please complete this form and an ETM Representative will contact you.
Typical turnaround time is three business days.

Name *

Email *

Company/Facility *

Provider Name *

Verification Type *
---Employment VerificationClaims History Verification

 
Provider’s Signed Release (pdf, doc, docx) *

Employment Verification Request Form (if Employment Verification is selected) (pdf, doc, docx) *