NORTH CAROLINA MEDICAL BOARD
PHYSICIAN REFERENCE FORM
TO APPLICANT: The North Carolina Medical Board requests completion of two reference forms. These forms must
be sent from the reference sources directly to the NC Medical Board by emailing the form
In addition, the forms must meet the following criteria:
a. They must have an original signature. Signature stamps will not be accepted.
b. They should be completed by physicians who have interacted with you within the past three years and who
are knowledgeable about your competence in your intended area of practice.
c. Reference forms cannot be from a relative.
Please be sure to indicate your name below for identification purposes.
Name of Applicant:
** On the application form, the applicant has agreed to release, discharge and exonerate any person
furnishing information from any and all liability of every nature and kind arising out of this furnishing
or inspection of such documents, records, other information or the investigation made by the North
Carolina Board. **
REFERENCE SOURCE: Please complete this form and return to the NC Medical Board. Your response is
confidential, pursuant to North Carolina law. Please print or type all information.
Important: The processing time for licensure directly depends on timely receipt of critical forms such as this.
Name MD/DO
Address City State Zip
Phone Number Email Address
1. How long have you known the applicant?
2. In what capacity are you acquainted with him/her?
If you answer “YES” to questions 3 - 9, you will need to provide an explanation.
3.
Have you ever received reports of poor medical practice by this
physician or have you discussed concerns you had about his/her
practice with medical staff officers at a hospital?
Yes No N/A
4.
Have you ever received reports of poor relationships between
this physician and other health care workers?
Yes No N/A
5.
Do you know of any derogatory information about this physician
with respect to his/her ability to practice medicine?
Yes No N/A
6.
Do you know if this physician has had and mental, emotional or
physical illnesses that have interfered with his/her medical
practice within the past five (5) years?
Yes No N/A
7.
Do you know if this physician has abused alcohol or drugs or
shown signs of chemical dependency within the past five (5)
years?
Yes No N/A
8.
Do you know of any judgements, awards, payments or
settlements regarding this physician?
Yes No N/A
9.
Do you know of any restrictions, limitations or other disciplinary
actions of any nature taken against this physician by a hospital
or other health care organization?
Yes No N/A
If you answer “NO” to questions 10 - 13, you will need to provide an explanation.
10.
Does this physician understand medical staff and hospital
policies and abide by these policies?
Yes No N/A
11.
Does this physician enjoy professional respect among his or her
colleagues and in the community where this physician
practices?
Yes No N/A
12.
Do you recommend this physician for unrestricted medical
licensure in North Carolina?
Yes No N/A
13.
Have you interacted with this physician within the past three
years and are you knowledgeable about their competence in
their intended area of practice?
Yes No N/A
** Additional comments are encouraged and assist the Board in evaluating the applicant. **
COMMENTS:
Signature Title
Name of Hospital (if applicable) Date
