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Sample Recommendation Form
Please print out this form to fill out or copy the portion between the horizontal lines to a word processing program to adapt to your needs.
Date:
Re:
Dear Dr. ______________,
The above listed physician has requested privileges in Medical Acupuncture, and has given your name as a reference with regard to his/her qualifications for these privileges. We would appreciate your response to the following questions:
- Does this physician routinely establish a diagnosis within the framework of Western medical thought?
- Does this physician routinely perform an appropriate medical work-up of the patient's condition?
- Does this physician routinely evaluate multiple treatment options and document the rationale for choosing Medical Acupuncture in each particular situation?
- Has this physician experienced a significant percentage of negative outcomes as a result of the use of Medical Acupuncture?
- Does this physician always use sterile technique when performing Medical Acupuncture?
- Does this physician exercise good judgement when commonly recognized medical treatment options for some conditions are available where Medical Acupuncture is also an option?
- Does this physician have an acceptable record with regard to the appropriate referrals of patients to specialists when warranted?
- How long have you known the applicant?
- On what type of interaction with this physician do you base your recommendations?
Comments:
Name (please print):
Signature _________________________ Date_________________
Read the Conditions for which Medical Acupuncture may be Indicated in a Hospital Setting.
List of Members with Hospital Privileges (requires Members login)
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