Peer Reference External

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 

[email protected]

(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.