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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)
*
Does Not Meet Standards
Meets Standards
Exceeds Standards
Excellent
Professionalism
*
Does Not Meet Standards
Meets Standards
Exceeds Standards
Excellent
Work Habits
*
Does Not Meet Standards
Meets Standards
Exceeds Standards
Excellent
Charting and Documentation
*
Does Not Meet Standards
Meets Standards
Exceeds Standards
Excellent
Clinical Skills
*
Does Not Meet Standards
Meets Standards
Exceeds Standards
Excellent
Clinical Knowledge
*
Does Not Meet Standards
Meets Standards
Exceeds Standards
Excellent
Competence
*
Does Not Meet Standards
Meets Standards
Exceeds Standards
Excellent
Adaptability
*
Does Not Meet Standards
Meets Standards
Exceeds Standards
Excellent
Do you have any reason to believe the provider would pose a risk to his/her patients?
*
Yes
No
Are there any issues you are aware of that might affect the provider’s work?
*
Yes
No
Has the provider ever lost his/her hospital or clinical privileges or been placed on probation?
*
Yes
No
Are you aware of any disciplinary actions or problems with the provider’s professional competence?
*
Yes
No
Are you aware of any past or pending malpractice claims against the provider?
*
Yes
No
Would you have any concerns with the provider treating a member of your family?
*
Yes
No
Are there any issues with the provider knowing his/her limitations and referring or consulting appropriately?
*
Yes
No
Would you hire this provider?
*
Yes
No
Your Signature
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Submit
Thanks for submitting!
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