Medical Staff Verifications

You've been asked to complete a professional reference for a health-care provider who has applied for appointment/reappointment to Osceola Medical Center. Please complete all sections of this online form with (*). If you have any questions or would like to submit a PDF, please email OMC's Credentialing at credentialing@myomc.org or fax 715-294-4822.

Professional reference for

Completed By

How long have you known the applicant?

In what setting did you observe the applicant?

Have you ever observed or been informed of any physical or mental health, substance abuse or dependence, or other problem which the applicant has or had that could impair his/her ability to practice medicine?

To the best of your knowledge, has the applicant’s medical license, DEA, clinical privilege, facility staff membership or other professional status been denied, revoked, modified or voluntarily or involuntarily surrendered?

If you answered "poor" for any of the above questions, please explain why below.

Applicant is qualified for clinical privileges requested:

Yes

Do you recommend this applicant for participation?

Recommend for participation

DO NOT recommend for participation

Please provide additional comments to indicate any reservations, concerns, comments, information or recommendations, which you believe, are relevant to the applicant’s request for participation.

By typing my name I am affixing my legal signature to the document and the legal effect cannot be denied simply because the signature is not in writing. - Your Signature

Thanks for submitting!

Medical Staff Verifications

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