Provider Peer Reference Form

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Provider Peer Reference Form

Your Name*:

Name of Provider Applying for Privileges*:

How Long have you known Applicant?*:

Nature of Relationship*:

Do you consider the personal qualifications, reputation, and character of the applicant, such that you would recommend him/her for medical staff appointment at Ohio County Healthcare?*:

Your knowledge of the applicant's professional ability and competence to perform the privileges requested is based upon:

Comments:

I believe him/her to be in adequate physical and mental health:

Can you recommend this provider to us without reservations?*:

If No, Please Indicate Why:

Additional Comments:

Ohio County Healthcare

Ohio County Healthcare is a non-profit Joint Commission accredited health system which provides a wide range of hospital, primary care and specialty physician services.

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What type of care do you seek?

Ohio County Healthcare offers a broad range of healthcare across a diverse landscape.

Ohio County Healthcare | 1211 Old Main Street, Hartford, KY 42347