PEER REFERENCE FORM EXTERNAL

Peer Reference External

Doc Name

Ref Name

Requested by

PEER REFERENCE FORM

PRIVILEGED AND CONFIDENTIAL
RECORD & PROCEEDING OF
GOVERNING BOARD/MEDICAL EXECUTIVE COMMITTEE REVIEW

PEER REFERENCE

RE:

Dear,

The above-referenced practitioner has applied for privileges at Alina Health, LLC and we are
requesting information from you as a professional reference. Your assistance in this matter is greatly
appreciated. If this letter or these materials raise any questions for you, please do not hesitate to
contact me.

Sincerely,

Alina Credentialing Team

credentialing@alinatelehealth.org

(281) 836-4735

Medical staff coordinator

Enclosure: Professional Reference Questionnaire

PRIVILEGED AND CONFIDENTIAL
RECORD & PROCEEDING OF
GOVERNING BOARD/MEDICAL EXECUTIVE COMMITTEE REVIEW

PROFESSIONAL REFERENCE QUESTIONNAIRE

Please answer all questions based on your personal knowledge and direct observations of the practitioner’s level of training, experience, and background. Your answers will be confidential and used in the credentialing process, or during any related due process procedures. If you need additional space to answer any questions, please use the back of the form or attach additional sheets. Your prompt return of this document is appreciated.

Clinical Knowledge/Clinical Judgment

Excellent

Average

Poor

Not observed

Please Explain

Patient Care/ Clinical Competence

Excellent

Average

Poor

Not observed

Please Explain

Ethical Conduct/Sense of Responsibility

Excellent

Average

Poor

Not observed

Please Explain

Physical/Mental Ability to perform privileges requested

Excellent

Average

Poor

Not observed

Please Explain

Competence / Technical and Clinical Skills

Excellent

Average

Poor

Not observed

Please Explain

Interpersonal/Communication Skills

Excellent

Average

Poor

Not observed

Please Explain

Display of Professionalism

Excellent

Average

Poor

Not observed

Please Explain

Practitioner-Patient Relationship

Excellent

Average

Poor

Not observed

Please Explain

Ability to Comply with Rules/Regulations

Excellent

Average

Poor

Not observed

Please Explain

How long have you known the applicant?

In what setting(s) did you observe the applicant? (i.e., of fice, hospital residency program, etc.)

Based on your knowledge of the practitioner , does the applicant have the training, experience and competence to perform the privileges currently being requested?

Yes

Please state reason

RECOMMENDATION:

Recommend highly as qualified and competent

Recommend with some reservation

Do not recommend (please explain)

Comments

Date / Time