Provider of Excellence Nomination Form

Provider of Excellence Nomination Form

Each year, in honor of National Doctors' Day, one outstanding provider from TriState Health will receive this award. Nominees should embody compassion, community impact, leadership, integrity, and dedication to patient-centered care.
To be considered for the 2026 Provider of Excellence Award, all nominations must be submitted by February 28, 2026. All submissions received after will be considered for the 2027 Provider of Excellence Award.
Nominator Information
Your Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Nominee Information
Name of Nominated Provider*
Please share a specific experience or moment that led you to nominate this provider.*
If you could say one thing to this provider, what would it be?*
Can we share your story with the provider you nominated?*

YesNo
If yes, can we include your name?*

YesNo
TriState Health may share your nomination/testimonial in its marketing and public relations efforts.*

YesNo
If yes, may they include your name?*

YesNo
TriState Marketing & Communications may contact you regarding your nomination/testimonial:*

YesNo
Should be Empty:

To be considered for the 2026 Provider of Excellence Award, all nominations must be submitted by February 28, 2026. All submissions received after will be considered for the 2027 Provider of Excellence Award.