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Availity Identity Verification Process

The document outlines the process for identity verification to access Availity Essentials, requiring users to complete and notarize a form within 45 days of application. It includes instructions for filling out user information, notarization, and mailing the original form to Availity. For assistance, users can contact Availity at 1-800-282-4548.

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abhishek mukherjee
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1K views1 page

Availity Identity Verification Process

The document outlines the process for identity verification to access Availity Essentials, requiring users to complete and notarize a form within 45 days of application. It includes instructions for filling out user information, notarization, and mailing the original form to Availity. For assistance, users can contact Availity at 1-800-282-4548.

Uploaded by

abhishek mukherjee
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

PRD v.7.1 Rev.

09/27/2023

Identity Verification Form


Instructions: To obtain access to Availity Essentials, Availity, LLC, requires that users verify their identity manually when
electronic verification is unsuccessful. Please complete this form (step 1), have it notarized (step 2), and return the original
notarized form to Availity (step 3). From the date of application in Availity Essentials, users have 45 days to submit this form
before the application is automatically rejected. For questions about this process, contact Availity at 1-800-282-4548.
Step 1: Enter user’s (applicant’s) information below. All fields are required.
CUSTOMER INFORMATION
Legal First Name Legal Last Name (current and previously used) Date of Birth (mm/dd/yyyy)
NITIN BHATNAGAR 10/30/1981
Phone Number (xxx) xxx-xxxx Country State (if US) Availity Application or User ID
Nitin001001

Step 2: Print and present this form to be signed in the presence of a notary with your government-issued photo ID.
NOTARY IDENTITY VERIFICATION
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of the document

Notary State: Notary County:

On the day of in the year before me, the undersigned, personally

appeared, is personally known to me or proved to me on the basis of satisfactory evidence to be the individual

whose name is subscribed to the within instrument and acknowledged to me that he/she/they executed the

same in his/her/their capacity, and that by his/her/their signature on the instrument, the individual, or the

person upon behalf of which the individual acted, executed the instrument.

I certify under PENALTY OF PERJURY under laws of the State of that the foregoing

paragraph is true and correct. WITNESS my hand and official seal below.

User/Applicant Signature (must match name in step 1) Date Signed

Notary Public Signature Notary Stamp/Seal:

Printed Name of Notary Public

Commission Number

Commission Expires

Step 3: Mail original notarized form to: Attn: Availity ID Verification Internal Use Only:
10004 N. Dale Mabry Hwy, Suite 106
Tampa, FL 33618
PROPRIETARY AND CONFIDENTIAL: This document is for the exclusive use of the individuals or entities listed above. If you have received
this in error, please notify the sender and destroy or return it. You are strictly prohibited from any disclosure, copying, distribution or reliance
on this information.

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