Professional Reference Form

Applicant Name:___________________________________________________Degree:________

License Number:__________________________________________________State:__________

Reference Name:__________________________________________________Degree:________

Note to the professional reference: We have attempted to make this procedure as easy as possible as we greatly appreciate your assistance in processing this application for membership. Please fill in the blanks or circle your responses. All information supplied by you will be held in strict confidence. Completed forms are to be returned directly to the ACADEMY OF MANAGED CARE PROVIDERS. Thank you.

I have known this applicant for: _________months / years

I am a: colleague / partner / acquaintance / other____________________________________________

My knowledge of his/her clinical skills is: minimal / moderate / extensive

I assess his/her clinical skills to be: poor / average / above average / excellent

His/her professional ethics are: questionable / acceptable / above reproach

His/her ability to provide quality care within a managed care environment is: minimal / moderate / extensive

His/her knowledge of managed care practice principles are: poor / average / excellent

I do / do not recommend this applicant for membership

Comments:_________________________________________________________________________

__________________________________________________________________________________

Signature Date

__________________________________________________________________________________

Position Degree /Title Profession

Please return this form directly to:

ACADEMY OF MANAGED CARE PROVIDERS

1945 Palo Verde Avenue, Suite 202
Long Beach, CA 90815-3445

(562) 682-3559 FAX (562) 799-3355