[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287067-105":53,"doc-detail-287067-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","provider-reference-letter-form","Provider Reference Letter Form","","This document provides a formal template for a professional reference letter required for medical practitioner licensure. It specifies strict submission requirements, including the necessity for direct mailing via US Mail from the referring physician and mandatory inclusion of professional titles. The form captures essential details such as the duration of professional association, the capacity of the relationship, the provider's clinical strengths, and a formal recommendation for licensure, ensuring a standardized, confidential, and verified evaluation process for regulatory boards.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/provider-reference-letter-form/287067/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/provider-reference-letter-form/287067.png","ImageObject",442,249,{"name":88,"@type":89},"Genevieve","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-20","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How must the reference letter be submitted?","Question",{"text":108,"@type":109},"The letter must be sent directly from the referring physician via US Mail; self-addressed envelopes and electronic submissions are not accepted.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information is required for the letter to be accepted?",{"text":113,"@type":109},"The letter must contain the professional title or suffix of the signee; otherwise, it will not be accepted.",{"name":115,"@type":106,"acceptedAnswer":116},"What details about the professional relationship are requested in the form?",{"text":117,"@type":109},"The form asks for the date of the last clinical contact, the capacity of the association, the duration of the professional relationship, the practitioner's strengths, and a formal recommendation for licensure.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287067,1789631855,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":4},1374391974585,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","The letter should reference a performance statement and how long you have known the applicant. Reference letters must be sent directly from the referring physician via US Mail. Self-addressed envelopes and electronic submissions will not be accepted. Reference letters that do not contain the professional title/suffix of the signee will not be accepted.  \n􀀍 I understand I am not required to provide the following information, and I ask that the following responses be kept confidential. If requested here, the Board will grant confidentiality for the below information.  \nProvider Reference for:  \n\n| Last Name | First Name | Middle Name |\n| --- | --- | --- |\n| Reference Completed by: |  |  |\n\nFull Name Title Email Phone  \nHospital, Clinic, Facility name at the time of association:  \n1. When was the last time you had clinical contact with the provider?  \n2. In what capacity were you acquainted with this provider?  \n3. How long have you known this provider?  \n4. What are this provider’s strengths?  \n5. Would you recommend this practitioner for licensure? Please explain.  \nPrint  \nSignature  \nDate","cbCaib23LsW7Tp83","https://ap.wps.com/l/cbCaib23LsW7Tp83","pdf",966969,"English","# Submission Guidelines\n## Provider Reference Information\n## Evaluator Details and Clinical Assessment","[{\"question\":\"How must the reference letter be submitted?\",\"answer\":\"The letter must be sent directly from the referring physician via US Mail; self-addressed envelopes and electronic submissions are not accepted.\"},{\"question\":\"What information is required for the letter to be accepted?\",\"answer\":\"The letter must contain the professional title or suffix of the signee; otherwise, it will not be accepted.\"},{\"question\":\"What details about the professional relationship are requested in the form?\",\"answer\":\"The form asks for the date of the last clinical contact, the capacity of the association, the duration of the professional relationship, the practitioner's strengths, and a formal recommendation for licensure.\"}]","Provider Reference Letter Form | PDF"]