Tri State Child Health Services

Policies, Procedures and Forms

Tri State Child Health Services, Inc., makes Credentialing and Recredentialing policies and procedures, office evaluation criteria and medical record review documents available below.

Download documents for Tri State Child Health Services, Inc. in portable document format (.pdf).

PHO Consent and Release (74k)
This form is signed by the provider applying for membership in the PHO
PHO CR-01 (76k)
Decisions regarding PHO membership
PHO CR-02 (142k)
Established credentialing and recredentialing criteria for providers
PHO CR-03 (133k)
Evaluation and intervention policy for impaired providers
PHO CR-04 (101k)
Confidentiality of peer review proceedings and records
PHO CR-05 (97k)
Provider office and medical record review standards
PHO CR-06 (107k)
Discipline, suspension, termination of credentialed providers
PHO CR-07 (110k)
Hearing and appellate review process
PHO NM-03 (108k)
Criteria for provider selection as PHO members
Medical Record Review (142k)
Evaluation document for on-site medical record reviews
Psych Medical Record Review (153k)
Evaluation document for on-site medical record review for Psychologist's office
PHO Psych Office Criteria (127k)
Site evaluation criteria for psychologist office
Site Criteria - Cincinnati Children's Hospital Medical Center (145k)
Evaluation document for on-site evaluation of providers office