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Form 3C.4Montefiore aesculapian Center & Montefiore Associate IPAs Confidential - lord Reference Evaluation TO: ________________________________________DATE:_____ September 8, 2009______ applier: ____Gabriel J. Kaufman, MD__________ DEPARTMENT: ______________________ The in a higher place listed physician or allied health provider is presently applying for clinical privileges at our facility and/or for membership in the Montefiore Associated IPAs. Please complete the form and return it directly drape to us via fax or mail at: Montefiore medical checkup Center/CMO 200 Corporate Drive, Yonkers, NY 10701 Phone:(914) 377-4690 Fax:(914) 377-4791 This force rating should be based on demonstrated subscribe to aboutance compared to that of what is more or less expected of a practician at his/her level of training, experience and background. I. birth OF REFERENCE TO APPLICANT 1. Your title or position at the sentence of observance: ______Pediatric Resident_________________ 2. Dates of observation: _07_/_01_/_05 to _06_/_30_/_07__ II. APPLICANT’S PROFESSIONAL KNOWLEDGE, SKILLS AND ATTITUDE 1. ar there any clinical areas, procedures, or patient impishness levels, which you would be concerned about allowing the applier to manage/ put to death if she/he were in put on with you?

No X Yes ( If yes, enthral condone: _________________________________________________ ____________________________________________________________ ___ ___________________ 2. Have you ever obse! rved or been advised of any physical, mental, health, drug, alcohol dependence or opposite problems which the applicant has that have or could potentially impair his/her efficiency to practice medicine in a reasonably pencil eraser and unspoiled manner? No X Yes ( If yes, please explain: _________________________________________________ ____________________________________________________________...If you need to get a full essay, order it on our website: BestEssayCheap.com

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