Affiliation Lookup Portal
UCSF Health St. Mary's Hospital
   
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I agree and acknowledge that I possess a signed release and immunity statement signed by the practitioner for which I am obtaining hospital verification information. Such signed release and immunity holds harmless and indemnifies UCSF St. Mary's Hospital and individuals providing information pursuant to this request, its medical staff, board of directors and each of their respective members and designees, the administration of such UCSF St. Mary's Hospital and its directors, officers, employees, representatives and agents, and each of them from any and all claims, demands or actions with respect to all acts, including without limitation, communications, reports, recommendations, or disclosures performed or made in connection with the request for the release of information pertaining to the practitioner's hospital affiliation with UCSF St. Mary's Hospital. My organization qualifies as a peer review body within the meaning of California Business and Professions Code Section 805 and therefore qualifies for all available immunities under state and federal laws. Furthermore, I understand that the provided information will be used solely with the intent to aid in the provider's qualification and fitness for medical or allied health practice, and my organization will maintain the confidentiality of this information in accordance with California Evidence Code 1157, or other similar out of state statues. Any other use of the provided information is strictly prohibited.