Get Eastpointe Provider Evaluation Form Eastpointe, 4.2.2012 - Eastpointe

Completing the Eastpointe Provider Evaluation Form is essential for evaluating the qualifications of providers applying to the Eastpointe network. This guide will provide clear, step-by-step instructions to help you effectively fill out the form online.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Enter the name of the applicant and the group name in the designated fields at the top of the form.
3. Select the type of evaluator or reference by checking the appropriate box next to one of the following options: Peer (Licensed Practitioner, not partner), Referring Physician or Practitioner, Chief of Department/Staff where practitioner has admitting privileges (Not partner), or Supervisor.
4. Provide details regarding your specialty and credentials in the space provided.
5. Clearly describe your relationship to the applicant in the designated field.
6. Indicate how long you have known the applicant by filling in the appropriate information.
7. Evaluate the applicant’s professional abilities by selecting one of the rating options: Excellent, Very Good, Good, Fair, or Poor.
8. Rate the applicant's ability to work and communicate with both physician and non-physician staff using the same rating options as in step 7.
9. Assess the applicant’s rapport with consumer/clients by selecting one of the rating options provided.
10. List the applicant's strengths and weaknesses as you see them in the designated area provided.
11. Answer the questions regarding any malpractice claims, problems with licensure, and any history of impairment due to drugs and/or alcohol with a Yes or No option, and provide any necessary details.
12. Indicate whether you would recommend this person as a provider for the Eastpointe network by selecting one of the options: Without reservation, With reservation, or Would not recommend.
13. Provide any additional information that may assist in evaluating the applicant in the final comments section.
14. Sign and date the form at the bottom. Also, be sure to include your printed name, telephone number, and address.
15. Once the form is completely filled out, you can save the changes, download, print, or share the form as necessary.

Complete your evaluation forms online for efficient processing!