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Physician Reviewer Information Sheet

I am interested in Joining HQSI's Physician Reviewer Network.

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* Contact Information

First Name:

Last Name:

Credentials:

NJ License #:

NPI#:

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* Practice Information

Practice Name:

Address:

City/Town:

State:

ZIP:

Office Fax:

Email Address:

Phone Number:

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* My Specialty is:

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* I am Board Certified in:

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* I certify that I:

	Yes	No
• Hold an unrestricted license to practice medicine in New Jersey	• Hold an unrestricted license to practice medicine in New Jersey Yes	• Hold an unrestricted license to practice medicine in New Jersey No
• Am in active practice in New Jersey at least 20 hours per week	• Am in active practice in New Jersey at least 20 hours per week Yes	• Am in active practice in New Jersey at least 20 hours per week No
• Have active staff privileges* in at least one NJ hospital or healthcare facility	• Have active staff privileges* in at least one NJ hospital or healthcare facility Yes	• Have active staff privileges* in at least one NJ hospital or healthcare facility No

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* Referral Information

	Yes	No
I was referred to HQSI by an HQSI physician reviewer	I was referred to HQSI by an HQSI physician reviewer Yes	I was referred to HQSI by an HQSI physician reviewer No

If yes, please provide the name of the HQSI physician reviewer

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* Signature:

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* Date:

*HQSI defines active staff privileges as a physician who is authorized on a regular, rather than infrequent or courtesy, basis to order the admission of patients to a facility, to perform diagnostic services in a facility, or to care for and treat patients in a facility (See 42 CFR 476.1).