Verification of Residency Registration, Completion & Certificate of Completion Request Form

NCOPE charges $30.00 dollars to verify registration / completion of residency for state licensing bodies and $20.00 dollars for residency completion certificate reprints (all residents will receive one complimentary certificate of completion when their residency program is completed) Please do not send cash. NCOPE accepts credit card, check, and money order payments. Credit card payment can be submitted directly to NCOPE using this form. Make checks and money orders payable to NCOPE and include a copy of the completed form. Requests can take up to 2 weeks to process. All state licensure verification letters will be sent certified mail directly to state licensure agency and a copy the letter will be mailed to the requester.

Former Resident Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Did your last name change since registering for residency? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Former Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Residency Program Information

Facility Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Residency Director {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Facility Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

End Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Would You Like to Verify the Opposite Discipline Residency as Well? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Was the Opposite Discipline Completed at the Same Facility? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Opposite Discipline Information

Facility Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Residency Director {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Facility Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

End Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Request Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Choose all services that apply

Only select Residency Registration Verification if you are entering into residency in a state whose licensing body requires notification by NCOPE to start the residency. If you have completed a residency that needs to be disclosed to a state licensing agency, select Completion of Residency Verification.

Identify the Organization Requesting the Verification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

State Licensure Verification - Details

State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

State #2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

State #3 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

State #4 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

State #5 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Comments {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Employer / Patient Care Facility

NCOPE will assess a $30 fee for completing verification documentation to an employer or patient care facility. Failure to provide all requested information will result in a delay in processing.

Organization Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Organization Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Contact Person at the Organization {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Contact Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Contact Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Provide a brief explanation why this verification is being requested by the organization listed above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Relevant Documentation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Provide copies of any documents that are relevant including releases from the former resident to disclose this information and/or forms that must be filled out by the NCOPE staff to provide to the organization.

Organization Charge {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Certificate Reprint - Details

Preferred Spelling of Recipients Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Please enter the name exactly as you would like it printed on the certificate.

Comments {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Other: Clearly explain the reason for the verification and how the verification should be submitted by the NCOPE staff. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Any verifications for a licensing agency, credentialling body, employer, or patient care facility will not be processed via the "Other" request pathway. Please select the appropriate reason for this request above in those instances.

Other: Relevant Documentation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Payment Method {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Please make the check / money order payable to:

NCOPE

Mail payments to:

Verification

c/o NCOPE

330 John Carlyle St

Suite 200

Alexandria, VA 22314

{~ Payment_Block_Label}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{binding Name}:	{binding displayValue}	---

{{ Cognito.resources['payment-amount-due'] + ":" }} {binding displayValue}

Verification of Residency Registration, Completion & Certificate of Completion Request Form

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}

{{ Cognito.resources['order-date-label'] }}: {binding displayValue}

{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:	({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:	{binding displayValue}

Verification of Residency Registration, Completion & Certificate of Completion Request Form

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}

{{ Cognito.resources['order-date-label'] }}: {binding displayValue}

{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:	({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:	{binding displayValue}

Former Resident Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Did your last name change since registering for residency? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Former Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Residency Program Information

Facility Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Residency Director {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Facility Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

End Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Would You Like to Verify the Opposite Discipline Residency as Well? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Was the Opposite Discipline Completed at the Same Facility? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Opposite Discipline Information

Facility Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Residency Director {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Facility Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

End Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Request Type {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Identify the Organization Requesting the Verification {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

State Licensure Verification - Details

State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

State #2 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

State #3 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

State #4 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

State #5 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Comments {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Employer / Patient Care Facility

NCOPE will assess a $30 fee for completing verification documentation to an employer or patient care facility. Failure to provide all requested information will result in a delay in processing.

Organization Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Organization Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact Person at the Organization {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Provide a brief explanation why this verification is being requested by the organization listed above. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Relevant Documentation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Organization Charge {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Certificate Reprint - Details

Preferred Spelling of Recipients Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Comments {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other: Clearly explain the reason for the verification and how the verification should be submitted by the NCOPE staff. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Other: Relevant Documentation {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Payment Method {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please make the check / money order payable to:

NCOPE

Mail payments to:

Verification

c/o NCOPE

330 John Carlyle St

Suite 200

Alexandria, VA 22314

Verification of Residency Registration, Completion & Certificate of Completion Request Form

Former Resident Information

Residency Program Information

Opposite Discipline Information

State Licensure Verification - Details

Employer / Patient Care Facility

Certificate Reprint - Details

{~ Payment_Block_Label}

Verification of Residency Registration, Completion & Certificate of Completion Request Form

{{ Cognito.resources['order-transaction-details-header'] }}

Verification of Residency Registration, Completion & Certificate of Completion Request Form

{{ Cognito.resources['order-transaction-details-header'] }}

Former Resident Information

Residency Program Information

Opposite Discipline Information

State Licensure Verification - Details

Employer / Patient Care Facility

Certificate Reprint - Details