Wentworth-Douglass Hospital logo

Verifying a Wentworth-Douglass Hospital
Medical/Professional Staff Member

This is the preliminary form for composing a Medical Staff Membership or Clinical Privileges Verification Letter.

By requesting a Letter you agree to these Terms of Use:
  1. You must have a current signed and valid application/release form from the provider granting you permission to access his/her information.
  2. Not to disclose or discuss any information obtained through this area of the Wentworth-Douglass Hospital web site except where it is required by your job function.
  3. That any information obtained here will be used for verification purposes only.
  4. Not to access information or use equipment other than that required to do your job, even if you don't tell anyone else.
  5. Not to breach confidentiality of any data obtained here.

If the practitioner you are searching for is not on the Web then fax your request and a signed release to the Wentworth-Douglass Hospital Medical Staff Office at 1 603-740-2460.

Last Name:    First Name:  
Birthdate mm/dd/yyyy: