Health Facility Peer Review Reporting Form (805 Report) 2026

1. Click ‘Get Form’ to open the Health Facility Peer Review Reporting Form (805 Report) in the editor.
2. Begin by selecting the appropriate reporting entity type by checking one of the boxes provided, such as 'Health Care Facility or Clinic' or 'Professional Society'.
3. Fill in the contact details for the Chief Executive Officer/Medical Director/Administrator and Chief of Medical Staff, including names, telephone numbers, and email addresses.
4. Indicate the licentiate type by checking one of the options: Physician, Podiatrist, or Licensed Midwife. Then provide their name and license number.
5. If applicable, check the box indicating this is a supplemental report and detail any actions taken along with dates and durations.
6. Select all relevant types of actions taken against the licentiate from the list provided, ensuring to attach additional sheets if necessary for detailed descriptions.
7. Complete the description of action section by attaching any relevant information regarding circumstances surrounding disciplinary actions.
8. Finally, ensure that both required signatures are included along with dates before submitting your completed form.

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