Mddo-verification-employment - Oregon - oregon 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the upper portion of the form. Enter your last name, first name, and any other names you have been known by. Include your middle name and date of birth in the specified format (mm/dd/yy).
3. Next, provide the name of the hospital, clinic, or facility where you were associated. Indicate your type of association by selecting from options such as Employee or Staff Member.
4. Fill in the last four digits of your Social Security Number and specify the dates of your association using the FROM and TO fields (mm/dd/yy).
5. Authorize the release of information by signing and dating the document at the bottom.
6. If applicable, ensure that any unusual circumstances are addressed in the lower section of the form. This includes checking appropriate responses for questions regarding limitations or concerns during your association.

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