_pages/claims/verify-3.html
---
title: Healthcare Provider Verification
---
{% include head.html %}
<link href="{{site.baseurl}}/stylesheets/form.css" type="text/css" rel="stylesheet" />
<body class="no-js layout-claims layout-claims-verify-3">
<a class="a-skip-to-main" href="#main">Skip to main content</a>
{% include site-header.html %}
<main role="main" id="main" class="page">
<div class="wrapper">
<h1>Healthcare provider verification complete</h1>
<p>Thanks for submitting information relevant to [claimant]’s claim for PFML benefits. Your responses, which appear below, were successfully recorded (you may <a href="#">print this page for your records</a>). Our office will contract you should we require additional information.</p>
<h2>Claim-verification details</h2>
<h3>Person claiming benefits</h3>
<dl>
<dt>Name</dt>
<dd>
<dl>
<dt>First</dt>
<dd>Jonathan</dd>
<dt>Middle</dt>
<dd>Dalton</dd>
<dt>Last</dt>
<dd>Wilson</dd>
</dl>
</dd>
</dl>
<h3>Physician</h3>
<dl>
<dt>Name</dt>
<dd>
<dl>
<dt>First</dt>
<dd>Rodrigo</dd>
<dt>Middle</dt>
<dd>James</dd>
<dt>Last</dt>
<dd>Menendez</dd>
</dl>
</dd>
<dt>Mailing address</dt>
<dd>123 High St.</dd>
<dt>Type or speciality</dt>
<dd>General practitioner</dd>
<dt>License</dt>
<dd>
<dl>
<dt>Number</dt>
<dd>123ABC</dd>
<dt>State or country where licensed</dt>
<dd>United States</dd>
</dl>
</dd>
</dl>
<h3>Patient</h3>
<dl>
<dt>Diagnosis</dt>
<dd>
<p>Lorem ipsum dolor sit amet, consectetur adipisicing elit, sed do eiusmod tempor incididunt ut labore et dolore magna aliqua. Ut enim ad minim veniam.</p>
</dd>
<dt>Primary ICD code</dt>
<dd>123ABC</dd>
<dt>Secondary ICD code</dt>
<dd>456DEF</dd>
<dt>Date first care needed</dt>
<dd><time>12/23/2014</time></dd>
<dt>Date you expect recovery</dt>
<dd>N/A</dd>
<dt>Hours per day will patient require claimant</dt>
<dd>4 hours</dd>
</dl>
</div>
</main>
{% include site-footer.html %}
</body>