v2.2 Rev.

1/8/2021

Identity Verification Form

Availity takes your privacy very seriously. One more step is required to validate your identity. Once completed, this step will provide you with
access to additional, secured services.

To complete your final step:

Print this form and present it, along with a valid government-issued ID, to a notary public and have your signature notarized. Complete the
User Information section and follow all user instructions. You will be notified by email when the form has been processed.

USER INFORMATION USER INSTRUCTIONS

Legal First Name Date of Birth (MM/DD/YYYY)
In this section, the user must
SivarajKumar 05/03/1985 complete all three steps:
Legal Last Name Availity User ID 1. Enter your personal information
in the fields.
Krishnamoothy sivarajk
State (if applicable) Country 2. Enter the Availity user ID that is
used with your Availity account.
3. Sign your name and enter
Signature Date (MM/DD/YYYY) today’s date.

NOTARY INFORMATION AND NOTARY SIGNATURES USER INSTRUCTIONS

This section is to be completed by the notary public In this section, the user must
Notary State (if applicable) Notary Country complete both steps:
1. Present one form of a valid
government-issued ID to the
I hereby certify that on this day of , 20 notary public.
2. Mail the completed, original
notarized form to the following
(write the name of the above referenced person as it appears on their government-issued ID) address:
personally appeared before me to sign or acknowledge this instrument. Attn: Availity ID Verification
10004 N. Dale Mabry Hwy
Valid Government-Issued ID (used as proof of identity; select one that applies) Suite 106
Driver’s License or Govt Identification Card Tampa, FL 33618
Social Security Card State: ______________
Passport
Birth Certificate Country: ____________
Military ID Card
Other (please specify) _____________________

Notary First Name Notary Last Name

Notary Signature

Notary Commission Expires Notary Seal

Notary Commission #

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THIS DOCUMENT IS A PROPRIETARY AND CONFIDENTIAL COMMUNICATION The documents accompanying this document may
contain confidential health information that is legally privileged. This information is intended only for the use of the individuals or entities listed
above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the
contents of these documents is strictly prohibited. If you have received this information in error, please notify the sender immediately and
arrange for the return or destruction of these documents.