Resident Training Verification

Effective July 1, 2021, the Graduate Medical Education Program will begin charging a $50 processing fee for residency verifications.

Complete the Authorization to Release Information fields below and click on the link to submit payment. Please allow five (5) business days from the time we receive payment to complete requests. If you have any questions, please feel free to contact Anastasia Palega at 760-424-7495 or [email protected].

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Organization Information

Please fill in the name, address, phone, and email information of the organization and the name of the individual requesting verification.

Requestor Name

Company/Institution

Address

Phone Number

Please enter the phone number using numbers only (ex. 8552479439)

Graduate Information

Please fill out the information below.

Name

Name of Program

Years of Training in Program

Date of Graduation

Authorization and Release

I authorize Desert Regional Medical Center Graduate Medical Education ("DRMCGME") department and its DRMCGME system affiliates, including respective individual employees, officers, representatives and agents, to verify all sources and information in any form from my graduate medical education file that DRMCGME deems relevant to the verification of my postgraduate training. I understand and agree that such information may include, without limitation, information relating to my education and training, character, and professional competence (including quality assurance and other privileged information). I hereby authorize DRMCGME, its employees, or agents for this purpose to provide all such information to the verifying agent. I acknowledge that DRMCGME, its officers and employees, and all such other individuals, institutions, and organizations may rely upon my authorization contained in this document and need to seek no further consent from me for this purpose. I further understand and acknowledge that all suc

I hereby release from all liability DRMCGME and their employees, officers and agents, and such other individuals, institutions or organizations, and assignees for all acts performed and statements made in good faith and without malice in connection with the request.

Please check if you acknowledge

Clicking this box acknowledges your authorization

You will be automatically redirected to the payment processing page after submitting this form.