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Form 3C.4Montefiore aesculapian Center & Montefiore Associate IPAs Confidential - passkey Reference Evaluation TO: ________________________________________DATE:_____ September 8, 2009______ applicant: ____Gabriel J. Kaufman, MD__________ DEPARTMENT: ______________________ The supra listed physician or allied health provider is concisely applying for clinical privileges at our facility and/or for membership in the Montefiore Associated IPAs. Please complete the form and return it directly covert to us via fax or mail at: Montefiore medical Center/CMO 200 Corporate Drive, Yonkers, NY 10701 Phone:(914) 377-4690 Fax:(914) 377-4791 This legions rating should be based on demonstrated pose aboutance compared to that of what is more or less expected of a practitioner at his/her level of training, experience and background. I. birth OF REFERENCE TO APPLICANT 1. Your title or position at the sentence of comment: ______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 mischievousness levels, which you would be concerned about allowing the applier to manage/ transact if she/he were in put on with you?

No X Yes ( If yes, enthral beg off: _________________________________________________ ____________________________________________________________ ______________________ 2. Have you ever observed or been advised of any ph! ysical, mental, health, drug, alcohol dependence or new(prenominal) problems which the applicant has that have or could potentially impair his/her force to practice medicine in a reasonably honest and unspoiled manner? No X Yes ( If yes, please explain: _________________________________________________ ____________________________________________________________...If you need to get a full essay, order it on our website: OrderCustomPaper.com

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