Physician Reference Leave this field blank Regarding Position Reference Name Position Contact Info Please answer the following to the best of your knowledge in regards to the Provider listed above: How many years have you been associated with the Provider? In what capacity? Colleague Training Director/Attending SupervisiorOther If you chose "other" please explain Describe the setting in which you observed the Provider work Is your clinical contact with the Provider Recent, within the last two years? YesNo Does the Provider know his/her limitations and refers or consults properly? YesNo Do you have any reason to believe the Provider would pose a risk to patients? YesNo Are you aware of any investigations or disciplinary actions or problems related to his/her professional competence? YesNo Are you aware of any issues that may affect the Provider’s work? YesNo Would you feel comfortable with the Provider treating you or a member of your family? YesNo Hypothetically, would you hire the Provider? YesNo If not, why? What are the Provider’s strongest characteristics? What weak or negative aspects are you aware of in the Provider’s performance? Please use the following scare to rate the Provider in each of the areas below: 1 = Poor, 2 = Average, 3 = Good, 4 = Excellent, N/A = Not Applicable Clinical skills 1234N/A Medical knowledge 1234N/A Professional competence 1234N/A Professional appearance 1234N/A Patient rapport 1234N/A Colleague rapport 1234N/A Ability to follow rules/procedures 1234N/A Contact Cathy Wingler, Credentialing Specialist at cwingler@christieclinic.com with any questions. Submit
