Narbha Peer Review Committee Sign-In Sheet

NARBHA PM Form 10.21.3

NARBHA Peer Review Committee

Conference Room

Date:

Time:

Sign-In Sheet

By signing this document, each committee member agrees to keep member level data confidential. In addition,

committee members may not participate in the review or evaluation of any case or clinical activity in which

she/he has been involved or has financial/personal investment.

Name

Representing

Signature

Other Attendees

Representing

Signature

Confidential Quality Assurance Document Protected by A.R.S. 36-2401 through 2404, A.R.S. 36-2917,

42 U.S.C . 1320c, 42 U.S.C. 11101-11152

PM Form 10.21.3-Sign In Sheet-Confidentiality/Conflict of Interest Agreement

Effective: 04/11/14

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Parent category: Business