Medical Credentialing Vote Form
Committee members: Please complete this form to record your credentialing vote and comments for the provider under review.
Provider Full Name
*
First Name
Last Name
Provider Specialty
*
Please Select
Internal Medicine
Family Medicine
Surgery
Pediatrics
Psychiatry
Obstetrics & Gynecology
Other
Type of Credentialing Application
*
Initial Appointment
Reappointment
Privilege Change
Date of Committee Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Committee Member Full Name
*
First Name
Last Name
Committee Member Role
*
Please Select
Chair
Physician Member
Nurse Member
Administrator
Other
Credentialing Vote Decision
*
Approve
Deny
Defer
Reason for Vote Decision
*
Please Select
Meets All Criteria
Incomplete Documentation
Concerns About Competency
Pending Additional Information
Other
Additional Comments
Submit Vote
Should be Empty: