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Provider Reference Form

This form is used to complete a reference for another provider who will be working for RelyMD as a telehealth provider.

Please rate the provider in the following areas:

Communication Abilities (patients, colleagues, physician and ancillary staff)
Work Habits
Charting and Documentation
Clinical Skills
Clinical Knowledge
Do you have any reason to believe the provider would pose a risk to his/her patients?
Are there any issues you are aware of that might affect the provider’s work?
Has the provider ever lost his/her hospital or clinical privileges or been placed on probation?
Are you aware of any disciplinary actions or problems with the provider’s professional competence?
Are you aware of any past or pending malpractice claims against the provider?
Would you have any concerns with the provider treating a member of your family?
Are there any issues with the provider knowing his/her limitations and referring or consulting appropriately?
Would you hire this provider?

Thanks for submitting!

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