AUTHORITY: Implementing and authorized by the Health Care Professionals Data Collection Act [410 ILCS 517].

SOURCE: Adopted at 24 Ill. Reg. 11476, effective August 24, 2001; amended at 26 Ill. Reg. 18416, effective December 15, 2002; expedited correction at 27 Ill. Reg. 14271, effective December 15, 2002; amended at 32 Ill. Reg. 4040, effective February 27, 2008.

SUBPART A: GENERAL

 

Section 965.110  Definitions

 

Act – the Health Care Professional Credentials Data Collection Act [410 ILCS 517].

 

Credentialing – the process of assessing and validating the qualifications of a health care professional.  (Section 5 of the Act)

 

Credentials data – those data, information, or answers to questions required by a health care entity, health care plan, or hospital to complete the credentialing or recredentialing of a health care professional.  (Section 5 of the Act)

 

Health care entity – any of the following entities that require the submission of credentials data in order for a health care professional to participate or provide care as a part of, or in conjunction with, the health care entity:

 

a health care facility or other health care organization licensed or certified to provide medical or health services in Illinois, other than a hospital;

 

a health care professional partnership, corporation, limited liability company, professional services corporation or group practice; or

 

an independent practice association or physician hospital organization. (Section 5 of the Act)

 

Entities licensed under other Acts that conduct credentialing in order for a health care professional to provide services, such as home health agencies, hospices, post-surgical recovery care centers, and ambulatory surgical treatment centers, are health care entities for the purposes of this Part.  Providers certified under the federal Medicare Program, such as Rural Health Clinics and End Stage Renal Disease treatment facilities, are also health care entities under this Part if they credential providers in order to provide services in their facilities/programs.

 

Health care plan – any entity licensed by the Department of Insurance as a prepaid health care plan or health maintenance organization or as an insurer that requires the submission of credentials data.  (Section 5 of the Act)

 

Health care professional – any person licensed under the Medical Practice Act of 1987 or any person licensed under any other Act subsequently made subject to the Act. (Section 5 of the Act)

 

Hospital – a hospital licensed under the Hospital Licensing Act or any hospital organized under the University of Illinois Hospital Act.  (Section 5 of the Act)

 

Single credentialing cycle – a process whereby, for purposes of recredentialing, each health care professional's credentials data are collected by all health care entities and health care plans during the same time period. (Section 5 of the Act)

 

Recredentialing – the process by which a health care entity, health care plan, or hospital ensures that a health care professional who is currently credentialed by the health care entity, health care plan, or hospital continues to meet the credentialing criteria used by the health care entity, health care plan, or hospital no more than once every 2 years. (Section 5 of the Act)

 

(Source:  Amended at 26 Ill. Reg. 18416, effective December 15, 2002)

 

Section 965.120  Referenced Materials

 

The following statutes and rules are referenced in this Part:

 

a)         State of Illinois statutes:

 

Health Care Professional Credentials Data Collection Act [410 ILCS 517]

Illinois Administrative Procedure Act [5 ILCS 100]

Medical Practice Act of 1987 [225 ILCS 60]

Hospital Licensing Act [210 ILCS 85]

University of Illinois Hospital Act [110 ILCS 330]

Administrative Review Law [735 ILCS 5/Art. III]

 

b)         State of Illinois rules:

 

Illinois Department of Public Health – Rules of Practice and Procedure in Administrative Hearings (77 Ill. Adm. Code 100)

 

Section 965.130  Use of Uniform Credentialing Forms

 

a)         The Department shall establish uniform forms for the purpose of credentialing, recredentialing, and information updates as required in Section 15 of the Act. The forms shall be coordinated to avoid the need for duplication of effort and information in submission.

 

b)         Hard copies and/or electronic copies of the forms shall be provided by the credentialing entity to applicants and current providers for use in their process.  Copies may be obtained through the Department electronically via the website at www.idph.state.il.us or in hard copy upon request.  No health care entity, health care plan, or hospital may require submission of the form in a specific format, either paper or electronic, until a date has been established under this Part whereby electronic submission can be required.

 

c)         Beginning January 1, 2002, all health care entities, health care plans, and hospitals that credential health care professionals shall only require the submission of the following forms, as specified in Section 15 of the Act:

 

1)         For credentialing, the Uniform Health Care Credentials Form (Appendix A).

 

2)         For recredentialing, the Uniform Health Care Recredentials Form (Appendix B).

 

3)         For updating credentials information, the Uniform Updating Form (Appendix C).

 

4)         Any additional credentials data requested.

 

d)         Credentialing and recredentialing applications and forms distributed before January 1, 2002 may continue to be accepted, but only through June 30, 2002. Health care plans, health care entities, and hospitals need not require that the forms adopted in this Part be filed for a health care professional whose credentialing is already in process prior to January 1, 2002.

 

e)         This Section does not prohibit or restrict the right of a health care entity, health care plan or hospital to request additional information necessary for credentialing or recredentialing.  (Section 15(i) of the Act) Nothing in this Part prohibits a pre-application process from being in place at a health care entity, health care plan, or hospital.  Individual attestation and release forms may be unique to each health care plan, hospital, or health care entity as a part of the credentialing or recredentialing process.

 

f)         The forms adopted in this Part cannot be altered in structure.  Nothing prohibits the use of pre-populated or double-sided forms as long as the structure of each page remains as adopted and as appearing on the Department website at www.idph.state.il.us.

 

g)         Nothing in the Act or this Part requires a health care entity, health care plan, or hospital to seek all of the credentials data that may be provided in the mandated credentials data gathering forms.  The extent to which a health care entity, health care plan, or hospital requires a health care professional to complete the applicable sections of the forms is within the discretion of the health care entity, health care plan, or hospital.  However, no health care entity, plan, or hospital may reject or deny a form that includes more information than the requirements of the individual entity, plan, or hospital.

 

h)         Keeping current and making changes in information, corrections, updates, and modifications to a health care professional's credentials data on file with health care entities, health care plans, and hospitals is the responsibility of the health care professional.  Data and information changes shall be submitted by the health care professional in accordance with the following time frames:

 

1)         Within 5 business days for state health care professional license revocation, federal drug enforcement agency license revocation, Medicare or Medicaid sanctions, revocation of hospital privileges, any lapse in professional liability coverage required by a health care entity, health care plan or hospital, or conviction of a felony.

 

2)         Within 45 days for any other change in the information from the date the health care professional knew of the change.  (Section 15(g) of the Act)

 

i)          All updates shall be made on the updating forms in Appendix C of this Part. (Section 15(g) of the Act) Updated information will be based on the information submitted to a health care plan, health care entity or hospital in the form in Appendix B of this Part.

 

j)          Collection of the information contained in the forms under this Part does not require health care entities, health care plans or hospitals to use all of the data and fields in the credentialing process. Nothing in the Act or this Part mandates whether or how credentials data must be verified or assessed as part of the credentialing process.  All decisions about whether and how to verify and assess any or all of the credentials data submitted to a health care entity, health care plan or hospital by a health care professional is exclusively within the lawful discretion of the health care entity, health care plan, or hospital that is credentialing that health care professional.

 

k)         Nothing in the Act or this Part prohibits a hospital from granting disaster privileges pursuant to the provisions of Section 10.4 of the Hospital Licensing Act.  When a hospital grants disaster privileges pursuant to Section 10.4 of the Hospital Licensing Act, that hospital is not required to collect credentials data pursuant to the Act.  (Section 15(m) of the Act)

 

(Source:  Amended at 32 Ill. Reg. 4040, effective February 27, 2008)

 

Section 965.140  Required Policies and Procedures

 

a)         Each health care entity, health care plan, hospital, or other credentialing entity shall adopt on or before January 1, 2002 and implement a policy or policies on the process of credentialing and credentials verification within their organization, including requests for additional information and confidentiality of information.

 

b)         Each health care entity and health care plan shall complete the process of verifying a health care professional's credentials data in a timely fashion and shall complete the process of credentialing or recredentialing of the health care professional within 60 days after the submission of all credentials data and completion of verification of the credentials data to be used in credentialing and recredentialing.  (Section 15(f) of the Act)

 

c)         The credentialing data noted as "confidential information" in the uniform forms in this Part are confidential as provided by law, including, but not limited to, Section 15(h) of the Act, Section 10.4 of the Hospital Licensing Act [210 ILCS 85/10.4] and Part 21 of Article VIII of the Code of Civil Procedure [735 ILCS 5/Art. VIII, Part 21], and otherwise may not be redisclosed without written consent of the health care professional.

 

d)         To make the form beneficial and effective for health care professionals, health care entities, health care plans, and hospitals, additional commonly collected business data are also being collected in the form.  Nothing in the Act or this Part shall be considered to prohibit sharing of business data for business purposes of the health care entity, health care plan, or hospital.

 

e)         Health care entities, health care plans and hospitals may delegate credentialing and recredentialing activities.

SUBPART B: ENFORCEMENT ACTION

 

Section 965.210  Complaints

 

a)         The Department will investigate complaints received regarding the Act and this Part.  Complaints shall be in writing to the Illinois Department of Public Health, Office of Health Care Regulation, 525 West Jefferson, 4th Floor, Springfield IL  62761, and shall contain sufficient facts to facilitate the investigation.

 

b)         Upon receipt of a complaint, the Department will acknowledge receipt of the complaint in writing.

 

c)         If the complaint contains allegations that would constitute a prima facie violation of the Act or this Part, an investigation will be conducted. The Department will investigate each complaint as quickly as possible based on available personnel and resources.

 

d)         The Department will use the most efficient and effective methods to investigate each complaint. This may include requirement of the production of documents, review of records, or on-site inspection.

 

Section 965.220  Notice of Violation

 

a)         When the Department determines through inspection, review of records, or other means of investigation that a violation of the Act or this Part has occurred, a notice of violation shall be served upon the health care plan, health care entity, hospital, or health care professional.

 

b)         Each notice of violation shall be in writing and shall include each of the following items:

 

1)         A description of the nature of the violation.

 

2)         A citation of the statutory provision or rule alleged to have been violated.

 

3)         A description of any action the Department may take under the Act, including the assessment of a penalty under Section 40 of the Act and Section 965.240 of this Part.

 

4)         A statement that the entity or person must submit a plan of correction.

 

5)         A description of the manner in which the entity or person may contest the notice of violation and the right to a hearing to contest the violation under Section 965.250 of this Part.

 

Section 965.230  Adverse Action

 

a)         An adverse action under this Part will be the imposition of a penalty.

 

b)         Adverse actions will be considered by the Department when substantial or continued failure to comply with the Act or this Part is found to have occurred.

 

c)         In determining whether to take adverse action pursuant to Section 40 of the Act in setting the amount of any fine or penalty, the Department will consider each of the following factors:

 

1)         The gravity of the violation or violations and the extent to which the provisions of the Act, other applicable statutes, or this Part were violated.

 

2)         The reasonable diligence exercised by the health care entity, health care plan, hospital, or professional to avoid the violation or violations or to reduce the potential harm to a patient or patients.

 

3)         Efforts by the health care entity, health care plan, hospital, or professional to correct the violation or violations.

 

4)         Any previous violations of the Act or this Part committed by the health care entity, health care plan, hospital, or professional.

 

Section 965.240  Fines and Penalties

 

a)         If the Department determines to impose a penalty or fine under Section 40 of the Act and this Part, the Department shall issue a notice of fine assessment.

 

b)         Each notice of fine assessment shall include each of the following items:

 

1)         A description of the violation or violations for which the fine is assessed.

 

2)         The amount of the fine as determined under Section 965.230 of this Part, which may be up to $1000 for the first violation and up to $5000 for each subsequent offense.  (Section 40 of the Act)

 

3)         A description of the manner in which the health care plan, health care entity, hospital, or health care professional may contest the fine assessment and the right to a hearing under the Department's Rules of Practice and Procedure in Administrative Hearings.

 

c)         If the health care plan, health care entity, hospital or professional cited under this Section does not comply with a written demand for payment within 30 days, the Director shall issue an order to certify to the Comptroller that the delinquent fines are due and owing from the licensee. The certification shall include any amounts due and owing as a result of a civil action pursuant to Section 40 of the Act. The Department shall send notice of the certification to the licensee and to any other person known to the Department who may be affected by the certification.

 

Section 965.250  Hearings

 

a)         Health care plans, health care entities, hospitals, or health care professionals may appeal certain actions of the Department under the Act and this Part.  If any of these parties desires to contest any Department action, it shall send a written request for a hearing to the Department within 10 days after receipt of the notice of the contested action. Following receipt of a request for a hearing, the Department shall conduct a hearing to review the contested action.

 

b)         Hearings conducted pursuant to the Act and this Part shall be conducted in accordance with the following:

 

1)         Article 10 of the Illinois Administrative Procedure Act.

 

2)         The Department's Rules of Practice and Procedure in Administrative Hearings.

 

c)         Final administrative decisions of the Department are subject to judicial review under the Administrative Review Law [735 ILCS 5/Art. III].

 

Section 965.300  Single Credentialing Cycle

 

a)         All health care entities and health care plans shall obtain recredentialing data on a health care professional according to the single credentialing cycle beginning July 1, 2002, except:

 

1)         when a health care professional submits initial credentials data to a health care entity or health care plan;

 

2)         when a health care professional's credentials data change substantively; or

 

3)         when a health care entity or health care plan requires recredentialing as a result of patient or quality assurance issues.

 

b)         Data collection for health care entities and health care plans will coincide with a single credentialing cycle that entitles health care entities and health care plans to collect recredentialing data once and not more than every 3 years, except as noted in subsection (a).

 

c)         Data collection:

 

1)         will be based on the last digit of each health care professional's Social Security number;

 

2)         will provide for a one month notification period for each digit during which each health care entity and health care plan notifies those persons being recredentialed of the time period during which data are expected to be submitted; and

 

3)         will provide for a 2 month collection period for each digit during which each health care entity and health care plan receives data from those persons being recredentialed.

 

d)         The single credentialing cycle reflects a 6 month "OPEN" period when health care entities and health care plans cannot collect data from a health care professional, except as noted in subsection (a).  This period coincides with the Illinois Department of Professional Regulation's licensing schedule of physicians.

 

e)         The single credentialing cycle is established as follows:

 

1)         For the years 2005/2008

 

July	OPEN
August	OPEN
September	OPEN
October	OPEN
November	OPEN
December	OPEN

 

2)         For the years 2003/2006/2009…

 

January	Notification (0's)
February	Collection of data
March	Collection of data
April	Notification (1's)
May	Collection of data
June	Collection of data
July	Notification (2's)
August	Collection of data
September	Collection of data
October	Notification (3's)
November	Collection of data
December	Collection of data

 

            3)         For the years 2004/2007/2010…

 

January	Notification (4's)
February	Collection of data
March	Collection of data
April	Notification (5's)
May	Collection of data
June	Collection of data
July	Notification (6's)
August	Collection of data
September	Collection of data
October	Notification (7's)
November	Collection of data
December	Collection of data

 

4)                  For the years 2005/2008/2011

 

January	Notification (8's)
February	Collection of data
March	Collection of data
April	Notification (9's)
May	Collection of data
June	Collection of data

 

f)         Once recredentialing is begun in accordance with the single credentialing cycle, a health care entity or health care plan may continue to request data from a health care professional outside of the published single credentialing cycle if it is not submitted by the deadline date published in the schedule.

 

g)         Nothing in this Section shall be construed to preclude, or otherwise exempt, a health care plan from monitoring, on an ongoing basis, in between recredentialing cycles, information on sanctions, limitations on licensure, and complaints against health care professionals consistent with guidelines issued by any entity that provides private accreditation to health care plans, or from meeting any quality assurance requirement of the entity related to credentialing for the purpose of accreditation or otherwise.

 

h)         The requirements of this Section apply only to health care plans and health care entities as defined in the Act [410 ILCS 517/5].

 

(Source:  Expedited correction at 27 Ill. Reg. 14271, effective December 15, 2002)

 

Section 965.310  Waiver from Single Credentialing Cycle

 

a)         A health care entity or health care plan may apply to the Director via letter for an exemption from the single credentialing cycle.  The request for consideration should be addressed to the Director's designee for administration of this program, the Office of Health Care Regulation.

 

1)         The request for waiver of this provision must be received by the Department on or before November 1 of the year prior to initiation of the established cycle.

 

2)         The request for waiver must contain, at a minimum, the following:

 

A)        a detailed explanation as to the undue hardship that would be created for the health care entity or health care plan in following the published single cycle.

 

B)        a detailed explanation and outline of the plan for conducting and time frame involved in the process that would be utilized in place of the published single cycle by the requesting health care entity or health care plan.

 

b)         The Director shall evaluate the request for exemption based upon whether  the plan is a small or unique health care entity for which compliance with the single credentialing cycle presents an undue hardship.

 

c)         The Department will notify waiver applicants of approval or denial by December 15 of the year prior to implementation of the single cycle.

 

d)         A denial of a waiver may be appealed in accordance with the procedures in Section 965.860 of this Part.

 

(Source:  Added at 26 Ill. Reg. 18416, effective December 15, 2002)

 

Section 965.APPENDIX A   Health Care Professional Credentialing and Business Data Gathering Form

 

STATE OF ILLINOIS

 

Health Care Professional Credentialing and Business Data Gathering Form

 

The Health Care Professional Credentials Data Collection Act [410 ILCS 517] requires that this form be collected from health care professionals by hospitals, health care entities, and health care plans that desire to credential such professional. Each hospital, health care entity, and health care plan may also require completion of supplemental forms.

 

INSTRUCTIONS

 

This form is for initial credentialing only.  Other forms are required for recredentialing and for updating information.  YOU ONLY HAVE TO FILL OUT AND SUBMIT WHAT IS REQUIRESTED BY THE CREDENTIALING ENTITY.  PLEASE REFER TO THE INSTRUCTIONS PROVIDED TO YOU BY THE ORGANIZATION YOU ARE APPLYING TO FOR THEIR REQUIREMENTS.

 

This form has been segmented into 2 different Chapters, each containing various sections:

 

Chapter A:  General and Practice Information

Chapter B:  Business Information

 

As previously noted, please consult the specific credentialing entity instructions for their individual Chapter or section requirements for submission.

 

GENERAL INSTRUCTIONS:  Wherever this application requests information but does not provide sufficient space to provide a complete response (for example, you have more licenses, specialties, work history, etc.) provide attachments that contain all of the information requested in the relevant section  OR  duplicate the relevant section as many times as necessary and attach it to the back of this application.

 

The data marked as “Confidential Information” shall be maintained in confidence to the extent required by law.  They may be used by the health care plan, entity or hospital and by their agents for credentialing and internal business purposes.  Other data contained in this form may be released.




ATTACHMENTS

 

Attach Forms A-F as needed to support "yes" responses in the Professional History section and copies of the following:

 

Curriculum Vitae

 

CONFIDENTIAL INFORMATION:

 

     All Current Professional Licenses

 

     Current Federal DEA License, If Applicable

 

     Current State Controlled Substances Licenses, If Applicable

 

     Current Professional Liability Insurance Face Sheet or Declaration of Insurance with Effective Date, Expiration Date and Amount Displayed Per Occurrence and In Aggregate

 

     Current CLIA Certificate, If Applicable

 

     Current W-9s, If Applicable

 

     ECFMG Certificate, If Applicable

 

     Professional  School  Diploma,  Residency  Certificates, Fellowship Certificates, and Board Certifications, As Applicable

 

AFFIRMATION OF INFORMATION

 

I represent and warrant that all of the information provided and the responses given are correct and complete to the best of my knowledge and belief.  I understand that falsification or omission of information may be grounds for rejection or termination, in addition to any penalties provided by law.  I further agree to promptly inform all entities to which this form was sent and not rejected of any change required to be updated by the Health Care Professional Credentialing and Business Data Gathering Update Form.

 

I understand that this application does not entitle me to participation in any hospital, health care entity, or health plan.

 

Applicant's Signature		Type or Print Name		Date

 

**PLEASE BE ADVISED THAT EACH HOSPITAL, HEALTH CARE ENTITY, AND HEALTH CARE PLAN MAY ALSO REQUIRE COMPLETION OF AN ATTESTATION AND RELEASE OF INFORMATION.




Chapter A

 

PRACTICE AND PROFESSIONAL INFORMATION

 

SECTION A.  GENERAL INFORMATION

 

Name:

Last

First

MI

Degree MD/DO/DC/PhD/MSW/DPM/ DDS/DMD/Other

List other names by which you have been known:

Last

First

MI

If you have been know by other names, please explain why your name changed:

Birth Date:

Place of Birth:

(mm/dd/yy)

City

State

County

Sex:

Male

Female

Language Fluency of Applicant:

English

Other

Spanish

U.S. Citizen?

Yes

No

If "no", do you have a legal right to reside permanently and work in the U.S.?

Yes

No

Resident Visa No:

CONFIDENTIAL INFORMATION

Social Security Number:

Emergency Contact Person:

Last

First

MI

Telephone Number:

(          )

Mailing Address:

Daytime Phone:

(          )

EMAIL Address:

Fax Number:

(          )

Check here if you have appended additional information for this Section.




Chapter A

 

SECTION B.  PROFESSIONAL INFORMATION

 

Illinois Professional License Number:

License Unlimited?

Yes

No

If "no", please explain limitation

Current and Previous Professional Licenses in Other States

State:

License #

Exp. Date:

(mm/dd/yy)

License Unlimited?

Yes

No

If "no", please explain limitation

State:

License #

Exp. Date:

(mm/dd/yy)

License Unlimited?

Yes

No

If "no", please explain limitation

State:

License #

Exp. Date:

(mm/dd/yy)

License Unlimited?

Yes

No

If "no", please explain limitation

Check here if you have appended additional information for this section.

Current Federal DEA License Number:

CONFIDENTIAL INFORMATION

DEA License Number Expiration Date:

License Unlimited?

Yes

No

(mm/dd/yy)

If "no", please explain limitation:

Check here if you have appended additional information for this section.

Current and Previous State Controlled Substance Numbers:

CONFIDENTIAL INFORMATION

State:

CS License #:

Expiration Date:

(mm/dd/yy)

State:

CS License #:

Expiration Date:

(mm/dd/yy)

State:

CS License #:

Expiration Date:

(mm/dd/yy)

Please identify all limitations related to the above Controlled Substances Numbers and explain limitations

Medicare Unique Provider ID# (UPIN):

National Provider Identification Number (NPI):

Medicaid ID#:

X-Ray Certification:

State:

Certificate #:

Expiration Date:

(mm/dd/yy)

Check here if you have appended additional information for this section.

 

 

Specialty I:

Are you Board Certified in Specialty I?

Yes

No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if  applicable):

(mm/yy)

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

No

If Certifying Boards taken, give date:

(mm/yy)

Certification Expiration Date, If Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Specialty/Subspecialty II:

Are you Board Certified in Specialty/Subspecialty II?

Yes

No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if  applicable):

(mm/yy)

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

No

If Certifying Boards taken, give date:

(mm/yy)

Certification Expiration Date, If Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Specialty/Subspecialty III:

Are you Board Certified in Specialty/Subspecialty III?

Yes

No

Are you Board Certified in Specialty III?

Yes

No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if  applicable):

(mm/yy)

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

No

If Certifying Boards taken, give date:

(mm/yy)

Certification Expiration Date, If Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Specialty/Subspecialty IV:

Are you Board Certified in Specialty/Subspecialty IV?

Yes

No

Are you Board Certified in Specialty IV?

Yes

No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if  applicable):

(mm/yy)

(mm/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

No

If Certifying Boards taken, give date:

(mm/yy)

Certification Expiration Date, If Any:

(mm/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/yy)

Check here if you have appended additional information for this section.

 




Chapter A

 

SECTION C.  PROFESSIONAL LIABILITY INSURANCE

 

Please provide information on all professional liability insurance carriers from whom you have received coverage in the past 10 years.

 

CURRENT PROFESSIONAL LIABILITY INSURANCE

 

CONFIDENTIAL INFORMATION:

 

Carrier:

Address:

Street

City

State

Zip

Policy Number:

Original Effective Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type coverage do you have?

Claims Made

Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

Address:

Street

City

State

Zip

Policy Number:

Original Effective Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type coverage do you have?

Claims Made

Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

 

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

 

CONFIDENTIAL INFORMATION:

Carrier:

Address:

Street

City

State

Zip

Policy Number:

Original Effective Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type coverage do you have?

Claims Made

Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

PREVIOUS PROFESSIONAL LIABILITY INSURANCE

CONFIDENTIAL INFORMATION:

Carrier:

Address:

Street

City

State

Zip

Policy Number:

Original Effective Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type coverage do you have?

Claims Made

Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

Check here if you have appended additional information for this section.

 




Chapter A

 

SECTION D.  EDUCATION AND TRAINING

 

If there are any gaps in your training (greater than 30 days), or if you have not completed any portion of your training, please explain on a separate sheet of paper and attach to this application.

 

 

MEDICAL/PROFESSIONAL SCHOOL

Institution Name:

Mailing Address:

Street

City

State

Zip

Telephone Number:

(         )

Fax Number:

(          )

Degree:

Year Graduated:

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

If you are a graduate of a foreign medical school, are you certified by the Educational

Commission for Foreign Medical Graduates (ECFMG)?

Yes

No

Date Issued:

Serial Number for ECFMG

Were you the subject of any disciplinary action during your time at this

institution?

Yes

No

(Attach an explanation of a “yes” answer.)

If you attended more than one medical/professional school, please check here and

attach an explanation that duplicates the information requested above:

INTERNSHIP

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

Type of internship:

Rotating

Straight

If straight, please list specialty:

 

Did you successfully complete this program?

Yes

No

If “no”, please attach

an explanation.

If more than one internship, please check here and attach additional information that duplicates

the information requested above:

Were you the subject of any disciplinary action during your time at this institution?

Yes

No

(Attach an explanation of a “yes” answer.)

FIRST RESIDENCY

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

Type of residency:

Did you successfully complete this program?

Yes

No

If “no”, please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

Yes

No

(Attach an explanation of a “yes” answer.)

SECOND RESIDENCY

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From

To:

(mm/yy)

(mm/yy)

Type of residency:

Did you successfully complete this program?

Yes

No

If “no”, please attach an

explanation.

If more than two residencies, please check here and attach additional information that duplicates the information requested above:

Were you the subject of any disciplinary action during your time at this institution?

Yes

No

(Attach an explanation of a “yes” answer.)

FIRST FELLOWSHIP

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

Type of fellowship:

Did you successfully complete this program?

Yes

No

If “no”, please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

Yes

No

(Attach an explanation of a “yes” answer.)

SECOND FELLOWSHIP

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates attended:

From:

To:

(mm/yy)

(mm/yy)

Type of fellowship:

Did you successfully complete this program?

Yes

No

If “no”, please attach an

explanation.

Were you the subject of any disciplinary action during your time at this institution?

Yes

No

(Attach an explanation of a “yes” answer.)

If more than two fellowships, please check here and attach additional information that duplicates the information requested above:

TEACHING EXPERIENCE/FACULTY APPOINTMENT (MOST RECENT)

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates:

From:

To:

Rank/Position, if applicable:

(mm/yy)

(mm/yy)

Were you the subject of any disciplinary action during your time at this institution?

Yes

No

(Attach an explanation of a “yes” answer.)

TEACHING EXPERIENCE/FACULTY APPOINTMENT (PREVIOUS)

Institution Name:

Department Chair or Program Director:

Last

First

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Dates:

From:

To:

Rank/Position, if applicable:

(mm/yy)

(mm/yy)

Were you the subject of any disciplinary action during your time at this institution?

Yes

No

(Attach an explanation of a “yes” answer.)

If more than two teaching experiences/faculty appointments, check here and attach additional information that duplicates the information above:




 

MEMBERSHIP STATUS – USE FOR SECTIONS E, F AND G
Please use the following key to indicate membership status in sections E (Hospital  Membership – Current and Pending), F (Hospital Membership – Previous), and G (Ambulatory Surgical Treatment Center Practice) below.
A.	Active	F.	Active Provisional Staff	K.	Pending
B.	Courtesy	G.	Senior Staff	L.	Other (Specify)
C.	Consulting	H.	Associate
D.	Adjunct	I.	Provisional
E.	Suspended/	J.	Affiliate
	Terminated/
	Resigned

 




 

Chapter A

 

SECTION E.  HOSPITAL MEMBERSHIP – CURRENT AND PENDING

 

Please list all hospitals at which you are a member of the Medical Staff and have clinical privileges or have applications for privileges pending.  (Include additional sheets if more than three hospitals.)

 

A.

Primary Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX #:

(      )

Department Telephone #:

(          )

Any limitations in your area of specialty at this hospital?

B.

Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX #:

(      )

Department Telephone #:

(          )

Any limitations in your area of specialty at this hospital?

C.

Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX #:

(      )

Department Telephone #:

(          )

Any limitations in your area of specialty at this hospital?

Check here if you have appended additional information for this section

 




 

Chapter A

 

SECTION F.  HOSPITAL MEMBERSHIP – PREVIOUS

 

Please list all hospitals where you previously held privileges other than during your Internship/Residency/Fellowship. Use the membership status key listed prior to Section E. (Include additional sheets if more than three hospitals.)

 

1.

Hospital Name

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office FAX #:

(      )

Department Telephone #:

(          )

2.

Hospital Name

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office FAX #:

(      )

Department Telephone #:

(          )

3.

Hospital Name

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Department/Division:

Medical Staff Office FAX #:

(      )

Department Telephone #:

(          )

Check here if you have appended additional information for this section




Chapter A

 

SECTION G.  AMBULATORY SURGICAL TREATMENT CENTER PRACTICE

 

Please list all ambulatory surgical treatment centers where you currently have clinical privileges. Use the Membership Status key listed prior to Section E. (Include additional sheets if more than three ASTCs.)

 

A.

Primary Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(          )

Telephone #:

(          )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

B.

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(          )

Telephone #:

(          )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

C.

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(          )

Telephone #:

(          )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Check here if you have appended additional information for this section.




 

Chapter A

 

SECTION H.  WORK HISTORY

 

List chronologically (most recent first) all work engagements (including employment, self-employment, service as an independent contractor, and military service) in the past 4 years. Do not duplicate internship, residency, and fellowship information previously reported. If there is any gap of greater than 30 days in chronology, explain it on a separate page.

 

Current work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To Present

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Check here if you have appended additional information for this section.

 




Chapter A

 

SECTION I.  PROFESSIONAL REFERENCES

 

Please list the names of three individuals who have personal knowledge (within the past 12 months) of your current clinical abilities, ethical character and interpersonal skills and who would be willing to provide this information upon request. Do not list partners or department chairpersons. Do not list relatives or people listed elsewhere in this credentialing form.

 

CONFIDENTIAL INFORMATION

1.

Name:

Title:

Last

First

MI

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Relationship:

Years Known:

2.

Name:

Title:

Last

First

MI

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Relationship:

Years Known:

3.

Name:

Title:

Last

First

MI

Degree

Specialty:

Mailing Address:

Street

City

State

Zip

Telephone Number:

(          )

Fax Number:

(          )

Relationship:

Years Known:

 




 

Chapter A

 

SECTION J.  PROFESSIONAL HISTORY:  CONFIDENTIAL

 

Submit with all applications. Please answer the following questions to the best of your knowledge with a "yes" or "no". If you answer "yes" to any questions, please complete FORM A. Please make copies of FORM A as needed and complete one form for each "yes" answer.

 

Adverse or Other Actions

 

1.	Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, revoked, canceled and/or subject to probation, either voluntarily or involuntarily, or has your application for a license ever been withdrawn?		Yes		No
2.	Have you ever been reprimanded and/or fined, been the subject of a complaint, and/or been notified in writing that you have been investigated as the possible subject of a criminal, civil or disciplinary action by any state or federal agency that licenses providers?		Yes		No
3.	Have you lost any board certifications, and/or failed to recertify?		Yes		No
4.	Have you been examined by a Certifying Board but failed to pass?		Yes		No
5.	Has any information pertaining to you, including malpractice judgements and/or disciplinary action, ever been reported to the National Practitioner Data Bank (NPDB) and/or any other practitioner data bank?		Yes		No
6.	Has your federal DEA number and/or state controlled substances license been restricted, limited, relinquished, suspended or revoked, either voluntarily or involuntarily, and/or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action with respect to your DEA or controlled substance registration?		Yes		No
7.	Have you or any of your hospital or ambulatory surgical treatment center (ASTC) privileges and/or membership been denied, revoked, suspended, reduced, placed on probation, proctored, placed under mandatory consultation or non-renewed?		Yes		No
8.	Have you voluntarily or involuntarily relinquished or failed to seek renewal of your hospital or ASTC privileges for any reason?		Yes		No
9.	Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending with respect to your hospital or ASTC privileges and/or your license?		Yes		No
10.	Have you ever been reprimanded, censured, excluded, suspended and/or disqualified from participating in Medicare, Medicaid, CHAMPUS and/or any other governmental health-related programs, or voluntarily withdrawn to avoid an investigation relating to those programs?		Yes		No
11.	Have Medicare, Medicaid, CHAMPUS or PRO authorities, and/or any other third party payors, brought charges against you for alleged inappropriate fees and/or quality-of-care issues?		Yes		No
12.	Have you been denied membership and/or been subject to probation, reprimand, sanction or disciplinary action, or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action by any health care organization, e.g., hospital, HMO, PPO, IPA, professional group or society, licensing board, certification board, PSRO, or PRO?		Yes		No
13.	Have you withdrawn an application or any portion of an application for appointment or reappointment for clinical privileges or staff appointment or for a license or membership in an IPA, PHO, professional group or society, health care entity or health care plan prior to a final decision to avoid a professional review or an adverse decision?		Yes		No

 

PROFESSIONAL LIABILITY ACTIONS

 

If you answer "yes" to any questions in this section, please complete FORM B. Please make copies of FORM B, if needed, and complete one for each "yes" answer.

 

1.	Have any professional liability judgements ever been entered against you?		Yes		No
2.	Have any professional liability claim settlements ever been paid by you and/or paid on your behalf?		Yes		No
3.	Are there any currently pending professional liability suits, actions and/or claims filed against you?		Yes		No
4.	Has any person or entity ever been sued for your clinical actions?		Yes		No

 

LIABILITY INSURANCE

 

If you answer "yes" to this question, please complete FORM C.

 

Have you ever been denied or voluntarily relinquished your professional liability insurance coverage, and/or have had your professional liability insurance coverage canceled or non-renewed or limits reduced?

Yes

No

 

CRIMINAL ACTIONS

 

If you answer "yes" to any questions in this section, please complete FORM D. Please make copies of FORM D, if needed, and complete one for each "yes" answer

 

1.	Have you been charged with or convicted of a crime (other than a minor traffic offense) in this or any other  state or country and/or do you have any criminal charges pending other than minor traffic offenses in this State or any other state or country?		Yes		No
2.	Have you been the subject of a civil or criminal complaint or administrative action or been notified in writing that you are being investigated as the possible subject at a civil, criminal or administrative action regarding sexual misconduct, child abuse, domestic violence or elder abuse?		Yes		No

 

MEDICAL CONDITION

 

If you answer "yes" to this question, please complete FORM E.

 

Do you have a medical  condition, physical defect or emotional impairment that in any way impairs and/or limits your ability to practice medicine with reasonable skill and safety?				Yes		No
CHEMICAL SUBSTANCES OR ALCOHOL ABUSE
If you answer "yes" to any questions in this section, please complete FORM F. Please make copies of FORM F, if needed, and complete one for each "yes" answer.
1.	Are you currently engaged in illegal use of any legal or illegal substances?			Yes		No
2.	Do you currently overuse and/or abuse alcohol or any other controlled substances?			Yes		No
3.	If you use alcohol and/or chemical substances, does your use in any way impair and/or limit your ability to practice medicine with reasonable skill and safety?			Yes		No
4.	Are you currently participating in a supervised rehabilitation program and/or professional assistance program that monitors you for alcohol and/or substance abuse?			Yes		No
INVESTMENTS
In the last 5 years have you and/or a member of your family purchased or made an investment in (other than securities of a publicly traded company), or otherwise have a business interest in any clinical laboratory, diagnostic or testing center, hospital, surgicenter, and/or other business dealing with the provision of ancillary health services, equipment or supplies?				Yes		No
If "yes", please provide explanation:

 




 Chapter B

 

SECTION K.  PRIMARY SITE INFORMATION

 

Please provide the following information for the primary site at which you practice.

Primary Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City

County

State

Zip

(          )

Main Telephone Number

Office Administrator –

Last

First

MI

(          )

(          )

Beeper Number

Fax Number

E-Mail

(          )

(          )

Emergency Number

Answering Service

Specialty practiced at this site:

Is your practice restricted within your specialty (e.g., by age or type of patient)?

Yes

No

If "yes", describe the restrictions:

Briefly describe your practice at this location, including any special practice focus or

equipment:

Are you currently accepting new patients at this location?

Yes

No

If "yes", describe any restrictions (e.g., appointment type, patient type):

Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

Indicate your office schedule at this location in the following table.  Write your specific hours in the appropriate spaces for each day.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Hours:

Please indicate standard patient waiting times to schedule an appointment at this site for:

New Patient

Existing Patient

Emergency Care

Urgent Care

Symptomatic Care (e.g., sore throat)

Routine Visits (e.g., blood pressure check)

Preventative Routine Care (e.g., school or annual physical)

Please provide the following regarding your practice at this site:

Maximum Number of Appointments per Hour

Average Waiting Time in Office (from scheduled appointment time to actual examination)

Average Response Time for Returning Patient Calls:

Acute or Urgent Situation:

Emergency Situation:

Routine Call:

Please check all procedures you perform at this site:

Age-appropriate immunizations

EKG

Drawing blood

Tympanometry/ audiometry screening

X-rays

Minor surgery

Pulmonary function studies

Flexible sigmoidoscopy

Laceration repair

Office gynecology (routine pelvic/PAP)

Asthma treatment

Allergy skin testing

Osteopathic/chiropractic manipulation

IV hydration/ treatment

Physical therapy

List any special skills or qualifications you or your office staff have that enhance your ability to practice medicine or treat certain patients or classes of patients. List separately any special language skills, such as fluency in a foreign language or proficiency in sign language.

Special Skills of Practitioner:

Special Skills of Staff:

Languages Spoken by Practitioner:

Languages Written by Practioner:

Languages Spoken by Staff:

Languages Written by Staff:

Is this practice site handicapped accessible (check all that apply)?

Building

Parking

Wheelchair

Restroom

Does this site employ paraprofessionals for direct patient care?

Yes

No

If "yes", is supervision always provided on premises during paraprofessional's direct patient

care?

Yes

No

Do the paraprofessionals bill under any of your Tax ID Numbers?

Yes

No

CONFIDENTIAL INFORMATION:  If "yes", list Tax ID Numbers used:

Lab service at this site:

Yes

No

If "yes", check whether:

Primary

Secondary

Tertiary

CLIA Waiver:

Yes

No

CLIA Expiration Date:

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Please provide the following information about physicians/practitioners who practice in this office:

Name:

Specialty:

Last

First

MI

Name:

Specialty:

Last

First

MI

Name:

Specialty:

Last

First

MI

 




Chapter B

 

SECTION L.  PRIMARY SITE TAX INFORMATION

 

Please provide the following information for your Primary Site.  Include tax information for each business arrangement you use at this site.  (Please include additional sheets if more than four applicable business arrangements.)

 

Business Arrangement #1
Name of Business Arrangement on SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:
Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site:			(       )
Business Arrangement #2
Name of Business Arrangement on SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:
Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site:			(       )
Business Arrangement #3
Name of Business Arrangement on SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:
Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site:			(       )
Business Arrangement #4
Name of Business Arrangement on SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:
Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site:			(       )

 




 

Chapter B

 

SECTION M.  ADDITIONAL SITE INFORMATION

 

Please provide the following information for each additional site at which you practice. If there is more than one additional site, copy and complete this section for each additional site.

 

Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City

County

State

Zip

(        )

Main Telephone Number

Office Administrator –

Last

First

MI

(        )

(        )

Beeper Number

Fax Number

E-Mail

(        )

(        )

Emergency Number

Answering Service

Specialty practiced at this site:

Is your practice restricted within your specialty (e.g., by age or type of patient)?

Yes

No

If "yes", describe the restrictions:

Briefly describe your practice at this location, including any special practice focus or

equipment:

Are you currently accepting new patients at this location?

Yes

No

If "yes", describe any restrictions (e.g., appointment type, patient type):

Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year?

Indicate your office schedule at this location in the following table.  Write your specific hours in the appropriate spaces for each day.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Hours:

Please indicate standard patient waiting times to schedule an appointment at this site for:

New Patient

Existing Patient

Emergency Care

Urgent Care

Symptomatic Care (e.g., sore throat)

Routine Visits (e.g., blood pressure check)

Preventative Routine Care (e.g., school or annual physical)

Please provide the following regarding your practice at this site:

Maximum Number of Appointments per Hour

Average Waiting Time in Office (from scheduled appointment time to actual examination)

Average Response Time for Returning Patient Calls:

Acute or Urgent Situation:

Emergency Situation:

Routine Call:

Please check all procedures you perform at this site:

Age-appropriate immunizations

EKG

Drawing blood

Tympanometry/audiometry screening

X-rays

Minor surgery

Pulmonary function studies

Flexible sigmoidoscopy

Laceration repair

Office gynecology (routine pelvic/PAP)

Asthma treatment

Allergy skin testing

Osteopathic/chiropractic manipulation

IV hydration/ treatment

Physical therapy

Acupuncture

List any special skills or qualifications you or your office staff have that enhance your ability to practice medicine or treat certain patients or classes of patients. List separately any special language skills, such as fluency in a foreign language or proficiency in sign language.

Special Skills of Practitioner:

Special Skills of Staff:

Languages Spoken by Practitioner:

Languages Written by Practitioner:

Languages Spoken by Staff:

Languages Written by Staff:

Is this practice site handicapped accessible (check all that apply)?

Building

Parking

Wheelchair

Restroom

Does this site employ paraprofessionals for direct patient care?

Yes

No

If "yes", is supervision always provided on premises during paraprofessional's direct patient

care?

Yes

No

Do the paraprofessionals bill under any of your Tax ID Numbers?

Yes

No

CONFIDENTIAL INFORMATION:  If "yes", list Tax ID Numbers used:

Lab service at this site:

Yes

No

If "yes", check whether:

Primary

Secondary

Tertiary

CLIA Waiver:

Yes

No

CLIA Expiration Date:

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

Specialty:

Last

First

MI

Degree

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION:   Tax ID#:

Name:

Specialty:

Last

First

MI

Degree

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Specialty:

Last

First

MI

Degree

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Specialty:

Last

First

MI

Degree

Address:

Telephone:

(        )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

CONFIDENTIAL INFORMATION: Tax ID#:

Please provide the following information about physicians/practitioners who practice in this office:

Name

Specialty:

Last

First

MI

Name

Specialty:

Last

First

MI

Name

Specialty:

Last

First

MI

 




Chapter B

 

SECTION N.  ADDITIONAL SITE TAX INFORMATION

 

Please provide the following information for each additional site at which you practice.  Include tax information for each business arrangement you use at this site.  (If there is more than one additional site or more than 5 business arrangements at any one site, please copy and complete this page for each additional site and business arrangement.)

 

Business Arrangement #1	Site #:
Name of Business Arrangement on SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:
Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site:					(       )
Business Arrangement #2	Site #:
Name of Business Arrangement on SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:
Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site:					(       )
Business Arrangement #3	Site #:
Name of Business Arrangement on SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:
Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site:					(       )
Business Arrangement #4	Site #:
Name of Business Arrangement on SS4 or W-9 Form:
Type of Arrangement (e.g., solo or group practice, IPA, PHO):
CONFIDENTIAL INFORMATION:  Tax ID for this Arrangement:
Billing Address, if Different from Primary Site:
Telephone Number, if Different from Primary Site:					(       )

 

End Uniform Health Care and Hospital CredentialsCredentialing and Business Data Gathering Form.

 

Attach Forms A-F As Required.




 

FORM A – ADVERSE AND OTHER ACTIONS

 

DUPLICATE this form as necessary to complete separate sheet for EACH occurrence that applies. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

Indicate the number of ONE of the questions in Section J to which you  answered "yes":

Question Number:

A.

Describe the circumstances surrounding this occurrence. Please include the date of the occurrence.

B.

Provide an explanation of any actions taken. Please include the date the action was taken.

C.

Provide the current status of the issue.

D.

If known:

Contact:

Department/Committee:

Address:

Street

City

State

Zip

Telephone Number:

(          )

Signature:

Date:

 




FORM B – PROFESSIONAL LIABILITY ACTIONS

 

DUPLICATE this form as necessary to complete a separate sheet for EACH action

or allegation. Use reverse side of this form if additional space is needed.

Applicant Name:

Last

First

MI

A.

Plaintiff’s Name:

Last

First

MI

If court case, Case Name & Case Number:

B.

Your Involvement in the Care (Attending, Consulting, Etc.):

C.

Your Status in the Case (Sole Defendant, Co-Defendant, Ownership Interest in

Provider Practice Named in Suit, Etc.)

D.

Allegations, including Patient Outcome, If Available:

E.

Date of Incident (mm/yy)

F.

Date Filed (mm/yy)

G.

Date Case Closed (mm/yy):

Case Resolution:

Dismissed

Judgement

Arbitration

Other

Settlement Out of Court

Pending

Mediation

H.

Amount Paid on Your Behalf (if any): $

I.

Professional Liability Insurer Name (if one was involved):

J.

Insurer Telephone Number:

(        )

K.

Policy Number:

L.

Insurer Address (Street, City, State, Zip Code):

Signature:

Date:

 




FORM C – LIABILITY INSURANCE

 

DUPLICATE this form as necessary to complete a separate sheet for EACH action or allegation. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

A.

History of Professional Liability Insurance (Please Check One)

Cancelled Voluntarily

Non-Renewed

Cancelled Involuntarily

Application Denied

B.

Carrier Name:

C.

Carrier Telephone Number:

(          )

D.

Policy Number:

E.

Carrier Address:

Street

City

State

Zip

F.

Dates of Coverage:

From (mm/yy):

To (mm/yy):

G.

Circumstances Involved:

Signature:

Date:

 




FORM D – CRIMINAL ACTIONS

 

DUPLICATE this form as necessary to complete a separate sheet for EACH incident. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

A.

Date of Incident (mm/yy):

B.

Date of Complaint or Conviction (mm/yy):

C.

Date of Resolution (mm/yy):

D.

Type of Resolution (Dismissed, Plea Bargain, Misdemeanor, Felony):

E.

Allegations:

F.

Details of Incident:

G.

Actions Taken Against You:

H.

Current Status of Situation:

I.

Medical Practice Privileges Affected as a Result of This Situation:

Signature:

Date:

 




FORM E – MEDICAL CONDITION

 

DUPLICATE this form as necessary to complete a separate sheet for EACH condition. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

A.

Describe this medical condition:

B.

To what extent does or could this condition affect your current ability to practice

medicine in your specialty area or to perform a full range of clinical activities?

C.

What is the current status of your condition?

D.

Provide the name and address of your personal physician/health care provider who can provide information about your health condition.

Name

Telephone Number

(          )

Last

First

MI

Degree

(          )

Last

First

MI

Degree

Signature:

Date:

 




FORM F – CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

 

DUPLICATE this from as necessary to complete a separate sheet for EACH chemical substance incident. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

Describe the substance you use:

A.

To what extent does, or could, your use of this substance affect your current ability to practice medicine in your specialty area or to perform a full range of clinical activities?

B.

Monitored by State Board Mandate (Name and Address)

C.

Monitored Voluntarily (Name and Address)

D.

Other information about the current status of your use of substances:

E.

Abstinent since (mm/yy):

F.

Provide the name and address of your personal physician/health care provider who can provide information about your treatment for alcohol or chemical substance use and can comment on what impact (if any) it has on your current/future professional practice.

Name:

Last

First

MI

Degree

Address:

Street

City

State

Zip

Telephone Number:

(          )

Signature:

Date:

 

 

Section 965.APPENDIX B   Health Care Professional Recredentialing and Business Data Gathering Form

 

STATE OF ILLINOIS

 

Health Care Professional Recredentialing and Business Data Gathering Form

 

The Health Care Professional  Credentials Data Collection Act [410 ILCS 517] requires that this form be collected from health care professionals by hospitals, health care entities, and health care plans that desire to recredential such professional.  Each hospital, health care entity, and health care plan may also require completion of supplemental forms.

 

INSTRUCTIONS

 

This form is for recredentialing only.  Other forms are required for credentialing and for updating information.  YOU ONLY HAVE TO FILL OUT AND SUBMIT WHAT IS REQUESTED BY THE CREDENTIALING ENTITY.  PLEASE REFER TO THE INSTRUCTIONS PROVIDED TO YOU BY THE ORGANIZATION YOU ARE APPLYING TO FOR THEIR REQUIREMENTS.

 

This form has been segmented into 2 different Chapters, each containing various sections:

 

Chapter A:  General and Practice Information

Chapter B:  Business Information

 

As previously noted, please consult the specific credentialing entity instructions for their individual Chapter or section requirements for submission.

 

GENERAL INSTRUCTIONS:  Wherever this application requests information but does not provide sufficient space to provide a complete response (for example, you have more licenses, specialties, work history, etc.) provide attachments that contain all of the information requested in the relevant section OR duplicate the relevant section as many times as necessary and attach it to the back of this application.

 

The data marked as "Confidential Information" shall be maintained in confidence to the extent required by law.  They may be used by the health care plan, entity or hospital and by their agents for credentialing and internal business purposes.  Other data contained in this form may be released.




ATTACHMENTS

 

Attach Forms A-F as needed to support "yes" responses in the Professional History section and copies of the following:

 

Curriculum Vitae

 

CONFIDENTIAL INFORMATION:

 

All Current Professional Licenses

 

Current Federal DEA Licenses, If Applicable

 

Current State Controlled Substance Licenses, If Applicable

 

Current Professional Liability Insurance Face Sheet or  Declaration of Insurance with Effective Date, Expiration Date and Amount Displayed Per Occurrence and In Aggregate

 

Current CLIA Certificate, If Applicable

 

Current W-9s, If Applicable

 

ECFMG Certificate, If Applicable

 

Professional School Diploma, Residency Certificates, Fellowship Certificates, and Board Certifications, As Applicable

 

AFFIRMATION OF INFORMATION

 

I represent and warrant that all of the information provided and the responses given are correct and complete to the best of my knowledge and belief.  I understand that falsification or omission of information may be grounds for rejection or termination, in addition to any penalties provided by law.  I further agree to promptly inform all entities to which this form was sent and not rejected of any change required to be updated by the Health Care Professional Credentialing and Business Data Gathering Update Form.

 

I understand that this application does not entitle me to participation in any hospital, health care entity, or health plan.

 

Applicant's Signature		Type or Print Name		Date

 

**PLEASE BE ADVISED THAT EACH HOSPITAL, HEALTH CARE ENTITY, AND HEALTH CARE PLAN MAY ALSO REQUIRE COMPLETION OF AN ATTESTATION AND RELEASE OF INFORMATION FORM.




CHAPTER A:

 

PRACTICE AND PROFESSIONAL INFORMATION

 

SECTION A. GENERAL INFORMATION

 

Name:

Last

First

MI

Degree

List other names by which you have been known:

Last

First

MI

If you have been known by other names, please explain why your name changed:

Birth Date:

(mm/dd/yy)

Sex:

Male

Female

U.S. Citizen?

Yes

No

If "no", do you have a legal right to reside permanently and work in the U.S.?

Yes

No

Resident Visa No:

CONFIDENTIAL INFORMATION

Social Security Number:

Emergency Contact Person:

Last

First

MI

Telephone Number:

(     )

Mailing Address:

Daytime Phone:

(     )

Fax Number:

(     )

EMAIL Address:

Check here if you have appended additional information for this section.

 




CHAPTER A:

SECTION B. PROFESSIONAL INFORMATION

 

Illinois Professional License Number:

License Unlimited?

Yes

No

If "no", please explain limitation

Current and Previous Professional Licenses in Other States

State:

License #

Exp. Date:

(mm/dd/yy)

License Unlimited?

Yes

No

If "no", please explain limitation

State:

License #

Exp. Date:

(mm/dd/yy)

License Unlimited?

Yes

No

If "no", please explain limitation

State:

License #

Exp. Date:

(mm/dd/yy)

License Unlimited?

Yes

No

If "no", please explain limitation

Check here if you have appended additional information for this section.

Current Federal DEA License Number:

CONFIDENTIAL INFORMATION

DEA License Number Expiration Date:

License Unlimited?

Yes

No

(mm/dd/yy)

If "no", please explain limitation:

Check here if you have appended additional information for this section.

Current and Previous State Controlled Substance Numbers:

CONFIDENTIAL INFORMATION

State:

CS License #:

Expiration Date:

(mm/dd/yy)

State:

CS License #:

Expiration Date:

(mm/dd/yy)

State:

CS License #:

Expiration Date:

(mm/dd/yy)

Please identify all limitations related to the above Controlled Substances Numbers and explain limitations

Medicare Unique Provider ID# (UPIN):

National Provider Identification Number (NPI):

Medicaid ID#:

X-Ray Certification:

State:

Certificate #:

Expiration Date:

(mm/dd/yy)

Check here if you have appended additional information for this section.

 

COMPLETE FOR EACH SPECIALTY

 

Specialty I:

Are you Board Certified in Specialty I?

Yes

No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if  applicable):

(mm/dd/yy)

(mm/dd/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

No

If Certifying Boards taken, give date:

(mm/dd/yy)

Certification Expiration Date, If Any:

(mm/dd/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/dd/yy)

Specialty/Subspecialty II:

Are you Board Certified in Specialty II?

Yes

No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if  applicable):

(mm/dd/yy)

(mm/dd/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

No

If Certifying Boards taken, give date:

(mm/dd/yy)

Certification Expiration Date, If Any:

(mm/dd/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/dd/yy)

Specialty/Subspecialty III:

Are you Board Certified in Specialty III?

Yes

No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if  applicable):

(mm/dd/yy)

(mm/dd/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

No

If Certifying Boards taken, give date:

(mm/dd/yy)

Certification Expiration Date, If Any:

(mm/dd/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/dd/yy)

Specialty/Subspecialty IV:

Are you Board Certified in Specialty IV?

Yes

No

If "yes", name of Certifying Board:

Date of Certification:

Date of Recertification (if  applicable):

(mm/dd/yy)

(mm/dd/yy)

If "no", have you taken or are you scheduled to take the Specialty Boards Certification?

Yes

No

If Certifying Boards taken, give date:

(mm/dd/yy)

Certification Expiration Date, If Any:

(mm/dd/yy)

If not taken, date scheduled to take Specialty Boards:

(mm/dd/yy)

Check here if you have appended additional information for this section.




 

CURRENT PROFESSIONAL LIABILITY INSURANCE

 

CONFIDENTIAL INFORMATION:

 

Carrier:

Address:

Street

City

State

Zip

Policy Number:

Original Effect Date:

Expiration Date:

(mm/dd/yy)

(mm/dd/yy)

Policy Limits:

Per Occurrence:

$

Aggregate:

$

Retroactive Date:

(mm/dd/yy)

What type coverage do you have?

Claims Made

Occurrence

Has any judgement or payment of claim or settlement amount exceeded the limits of this coverage?

Yes

No

 




 

MEMBERSHIP STATUS – USE FOR SECTIONS C AND D
Please use the following key to indicate membership status in sections C (Hospital  Membership – Current  and  Pending) and D (Ambulatory Surgical Treatment Center Practice) below.
A.	Active	F.	Active Provisional Staff	K.	Pending
B.	Courtesy	G.	Senior Staff	L.	Other (Specify)
C.	Consulting	H.	Associate
D.	Adjunct	I.	Provisional
E.	Suspended/	J.	Affiliate
	Terminated/
	Resigned

 




 

SECTION C. HOSPITAL MEMBERSHIP – CURRENT AND PENDING

 

Please list all hospitals at which you are a member of the Medical Staff and have clinical privileges or have applications for privileges pending.  (Include additional sheets if more than three hospitals.)

 

A.

Primary Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX:

(    )

Department Telephone #:

(     )

Do you have admitting privileges at this hospital?

Yes

No

Any limitations in your area of specialty at this hospital?

B.

Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX:

(    )

Department Telephone #:

(     )

Do you have admitting privileges at this hospital?

Yes

No

Any limitations in your area of specialty at this hospital?

C.

Other Hospital

Hospital Name:

Address:

Street

City

State

Zip

Membership Status (see above):

Dates:

To Present

From (mm/yy)

Department/Division:

Medical Staff Office FAX:

(    )

Department Telephone #:

(     )

Do you have admitting privileges at this hospital?

Yes

No

Any limitations in your area of specialty at this hospital?

Check here if you have appended additional information for this section

 




 

SECTION D. AMBULATORY SURGICAL TREATMENT CENTER PRACTICE

 

Please list all ambulatory surgical treatment centers where you currently have clinical privileges. Use the Membership Status key at the top of page 7. (Include additional sheets if more than three ASTCs.)

 

A.

Primary Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(     )

Telephone #:

(     )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

B.

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(     )

Telephone #:

(     )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

C.

Other Ambulatory Surgical Treatment Center

ASTC Name:

Address:

Street

City

State

Zip

FAX#:

(     )

Telephone #:

(     )

Membership Status (see above):

Dates:

From (mm/yy)

To (mm/yy)

Check here if you have appended additional information for this section.




 

SECTION E. WORK HISTORY

 

List chronologically (most recent first) all work engagements (including employment, self-employment, service as an independent contractor, and military service) in the past 4 years. Do not duplicate internship, residency, and fellowship information previously reported. If there is any gap of greater than 30 days in chronology, explain it on a separate page.

 

Current work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To Present

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Previous work place:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Title or Professional Occupation:

Time in this employment:

From:

To:

(mm/yy)

(mm/yy)

Check here if you have appended additional information for this section.

 




 

SECTION F. MEDICAL EDUCATION/CLINICAL TRANING UPDATE

 

Please provide an update of your medical education and clinical training over the past four years.  Do not duplicate internship, residency, and fellowship information previously reported.  (Attached additional sheets if necessary.)

 

FIRST UPDATE

Fellowship

Residency

Other

Institution Name:

Department Chair or Program Director:

Last Name

First Name

MI

Degree

Mailing Address:

Street

City

State

Zip

Telephone Number:

(     )

Fax Number:

(     )

Dates attended:

From:

To:

mm/yy

mm/yy

Type of internship:

Rotating

Straight

If straight, please list specificaly

Did you successfully complete this program? If no, please list specialty:

Yes

No

Were you the subject of any disciplinary action during your attendance at this institution?

(Attached an explanation of a "Yes" answer.)

Yes

No

SECOND UPDATE

Fellowship

Residency

Other

Institution Name:

Department Chair and Program Director:

Last Name

First Name

MI

Degree

Mailing Address:

Street

City

State

Zip

Dates attended:

From:

To:

Mm/yy

Mm/yy

Types of internship:

Rotating

Straight:

If straight, please list specialty:

Did you successfully complete this program?

Yes

No

Were you the subject of any disciplinary action during your attendance

this institution?

Yes

No

(Attach an explanation of a "Yes" answer.)

Check here if you have appended additional information for this section:




 

SECTION G. PROFESSIONAL HISTORY:  CONFIDENTIAL

 

Submit with all applications. Please answer the following questions to the best of your knowledge with a "yes" or "no". If you answer "yes" to any questions, please complete FORM A. Please make copies of FORM A as needed and complete one form for each "yes" answer.

 

Adverse or Other Actions

 

1.	Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, revoked, cancelled and/or subject to probation, either voluntarily or involuntarily, or has your application for a license ever been withdrawn?		Yes		No
2.	Have you ever been reprimanded and/or fined, been the subject of a complaint, and/or been notified in writing that you have been investigated as the possible subject of a criminal, civil or disciplinary action by any state or federal agency that licenses providers?		Yes		No
3.	Have you lost any board certifications, and/or failed to recertify?		Yes		No
4.	Have you been examined by a Certifying Board but failed to pass?		Yes		No
5.	Has any information pertaining to you, including malpractice judgements and/or disciplinary action, ever been reported to the National Practitioner Data Bank (NPDB) and/or any other practitioner data bank?		Yes		No
6.	Has your federal DEA number and/or state controlled substances license been restricted, limited, relinquished, suspended or revoked, either voluntarily or involuntarily, and/or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action with respect to your DEA or controlled substance registration?		Yes		No
7.	Have you or any of your hospital or ambulatory surgical treatment center (ASTC) privileges and/or membership been denied, revoked, suspended, reduced, placed on probation, proctored, placed under mandatory consultation or non-renewed?		Yes		No
8.	Have you voluntarily or involuntarily relinquished or failed to seek renewal of your hospital or ASTC privileges for any reason?		Yes		No
9.	Have any disciplinary actions or proceedings been instituted against you and/or are any disciplinary actions or proceedings now pending with respect to your hospital or ASTC privileges and/or your license?		Yes		No
10.	Have you ever been reprimanded, censured, excluded, suspended and/or disqualified from participating in Medicare, Medicaid, CHAMPUS and/or any other governmental health-related programs, or voluntarily withdrawn to avoid an investigation relating to those programs?		Yes		No
11.	Have Medicare, Medicaid, CHAMPUS or PRO authorities, and/or any other third party payors, brought charges against you for alleged inappropriate fees and/or quality-of-care issues?		Yes		No
12.	Have you been denied membership and/or been subject to probation, reprimand, sanction or disciplinary action, or have you ever been notified in writing that you are being investigated as the possible subject of a criminal or disciplinary action by any health care organization, e.g., hospital, HMO, PPO, IPA, professional group or society, licensing board, certification board, PSRO, or PRO?		Yes		No
13.	Have you withdrawn an application or any portion of an application for appointment or reappointment for clinical privileges or staff appointment or for a license or membership in an IPA, PHO, professional group or society, health care entity or health care plan prior to a final decision to avoid a professional review or an adverse decision?		Yes		No

 

PROFESSIONAL LIABILITY ACTIONS

 

If you answer "yes" to any questions in this section, please complete FORM B. Please make copies of FORM B, if needed, and complete one for each "yes"answer.

 

1.	Have any professional liability judgements ever been entered against you?		Yes		No
2.	Have any professional liability claim settlements ever been paid by you and/or paid on your behalf?		Yes		No
3.	Are there any currently pending professional liability suits, actions and/or claims filed against you?		Yes		No
4.	Has any person or entity ever been sued for your clinical actions?		Yes		No

 

LIABILITY INSURANCE

 

If you answer "yes" to this question, please complete FORM C.

 

Have you ever been denied or voluntarily relinquished your professional liability insurance coverage, and/or have had your professional liability insurance coverage canceled or non-renewed or limits reduced?

Yes

No

 

CRIMINAL ACTIONS

 

If you answer "yes" to any questions in this section, please complete FORM D. Please make copies of FORM D, if needed, and complete one for each "yes" answer

 

1.	Have you been charged with or convicted of a crime (other than a minor traffic offense) in this or any other  state or country and/or do you have any criminal charges pending other than minor traffic offenses in this State or any other state or country?		Yes		No
2.	Have you been the subject of a civil or criminal complaint or administrative action or been notified in writing that you are being investigated as the possible subject at a civil, criminal or administrative action regarding sexual misconduct, child abuse, domestic violence or elder abuse?		Yes		No

 

MEDICAL CONDITION

 

If you answer "yes" to this question, please complete FORM E.

 

Do you have a medical  condition, physical defect or emotional impairment that in any way impairs and/or limits your ability to practice medicine with reasonable skill and safety?				Yes		No
CHEMICAL SUBSTANCES OR ALCOHOL ABUSE
If you answer "yes" to any questions in this section, please complete FORM F. Please make copies of FORM F, if needed, and complete one for each "yes" answer.
1.	Are you currently engaged in illegal use of any legal or illegal substances?			Yes		No
2.	Do you currently overuse and/or abuse alcohol or any other controlled substances?			Yes		No
3.	If you use alcohol and/or chemical substances, does your use in any way impair and/or limit your ability to practice medicine with reasonable skill and safety?			Yes		No
4.	Are you currently participating in a supervised rehabilitation program and/or professional assistance program that monitors you for alcohol and/or substance abuse?			Yes		No
INVESTMENTS
In the last 5 years have you and/or a member of your family purchased or made an investment in (other than securities of a publicly traded company), or otherwise have a business interest in any clinical laboratory, diagnostic or testing center, hospital, surgicenter, and/or other business dealing with the provision of ancillary health services, equipment or supplies?				Yes		No
If "yes", please provide explanation:

 




 

SECTION H. PRIMARY SITE INFORMATION

 

Please provide the following information for the primary site at which you practice.

Primary Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City

County

State

Zip

(     )

Main Telephone Number

Office Administrator –

Last

First

MI

(     )

(     )

Beeper Number

Fax Number

E-Mail

(     )

(     )

Emergency Number

Answering Service

Are you currently accepting new patients at this location?  Yes  No

If "yes", describe any restrictions (e.g., appointment type, patient type):

Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

 

List any special skills or qualifications you or your office staff have that enhance your ability to practice medicine or treat certain patients or classes of patients. List separately any special language skills, such as fluency in a foreign language or proficiency in sign language.

Special Skills of Practitioner:

Special Skills of Staff:

Languages Spoken by Practitioner:

Languages Written by Practioner:

Languages Spoken by Staff:

Languages Written by Staff:

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

 

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

 

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

 

CONFIDENTIAL INFORMATION: Tax ID#:

 




 

SECTION I. ADDITIONAL SITE INFORMATION

 

Please provide the following information for each additional site at which you practice. If there is more than one additional site, copy and complete this section for each additional site.

 

Please provide the following information for the primary site at which you practice.

Primary Site

Group/Business Name

Building Name

Office Address – Number and Street – Suite

City

County

State

Zip

(     )

Main Telephone Number

Office Administrator –

Last

First

MI

(     )

(     )

Beeper Number

Fax Number

E-Mail

(     )

(     )

Emergency Number

Answering Service

Are you currently accepting new patients at this location?  Yes  No

If "yes", describe any restrictions (e.g., appointment type, patient type):

Please provide the number of active patients enrolled with you at this site:

Please provide the number of patient visits you have at this site per year:

 

List any special skills or qualifications you or your office staff have that enhance your ability to practice medicine or treat certain patients or classes of patients. List separately any special language skills, such as fluency in a foreign language or proficiency in sign language.
	Special Skills of Practitioner:
	Special Skills of Staff:
	Languages Spoken by Practitioner:
	Languages Written by Practitioner:
	Languages Spoken by Staff:
	Languages Written by Staff:

 

Please provide the following information about physicians/practitioners who provide coverage for patients enrolled at this site when you are not available.

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

 

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

 

CONFIDENTIAL INFORMATION: Tax ID#:

Name:

Last

First

MI

Degree

Specialty:

Address:

Telephone:

(     )

Street

City

State

Zip

Availability:

Days

Nights

Weekends

Holidays

 

CONFIDENTIAL INFORMATION: Tax ID#:

 

End Recredentialing and Business Data Gathering Form.

Attach Forms A-F As Required.

 




FORM A – ADVERSE AND OTHER ACTIONS

 

DUPLICATE this form as necessary to complete separate sheet for EACH occurrence that applies. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

Indicate the number of ONE of the questions in Section I to which you  answered "yes":

Question Number:

A.

Describe the circumstances surrounding this occurrence. Please include the date of the occurrence.

B.

Provide an explanation of any actions taken. Please include the date the action was taken.

C.

Provide the current status of the issue.

D.

If known:

Contact

Department/Committee:

Address:

Street

City

State

Zip

Telephone Number:

(     )

Signature:

Date:

 




FORM B – PROFESSIONAL LIABILITY ACTIONS

 

DUPLICATE this form as necessary to complete a separate sheet for EACH action

or allegation. Use reverse side of this form if additional space is needed.

Applicant Name:

Last

First

MI

A.

Plaintiff’s Name:

Last

First

MI

If court case, Case Name & Case Number:

B.

Your Involvement in the Care (Attending, Consulting, Etc.)

C.

Your Status in the Case (Sole Defendant, Co-Defendant, Ownership Interest in

Provider Practice Named in Suit, Etc.)

D.

Allegations, including Patient Outcome, If Available:

E.

Date of Incident (mm/yy)

F.

Date Filed (mm/yy)

G.

Date Case Closed (mm/yy):

Case Resolution:

Dismissed

Judgement

Arbitration

Other

Settlement Out of Court

Pending

Mediation

H.

Amount Paid on Your Behalf (if any): $

I.

Professional Liability Insurer Name (if one was involved):

J.

Insurer Telephone Number:

(        )

K.

Policy Number:

L.

Insurer Address (Street, City, State, Zip Code):

Signature:

Date:

 




FORM C – LIABILITY INSURANCE

 

DUPLICATE this form as necessary to complete a separate sheet for EACH action or allegation. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

A.

History of Professional Liability Insurance (Please Check One)

Cancelled Voluntarily

Non-Renewed

Cancelled Involuntarily

Application Denied

B.

Carrier Name:

C.

Carrier Telephone Number:

(     )

D.

Policy Number:

E.

Carrier Address:

Street

City

State

Zip

F.

Dates of Coverage:

From (mm/yy):

To (mm/yy):

G.

Circumstances Involved:

Signature:

Date:

 




FORM D – CRIMINAL ACTIONS

 

DUPLICATE this form as necessary to complete a separate sheet for EACH incident. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

A.

Date of Incident (mm/yy):

B.

Date of Complaint or Conviction (mm/yy):

C.

Date of Resolution (mm/yy):

D.

Type of Resolution (Dismissed, Plea Bargain, Misdemeanor, Felony):

E.

Allegations:

F.

Details of Incident:

G.

Actions Taken Against You:

H.

Current Status of Situation:

I.

Medical Practice Privileges Affected as a Result of This Situation:

Signature:

Date:

 




FORM E – MEDICAL CONDITION

 

DUPLICATE this form as necessary to complete a separate sheet for EACH condition. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

A.

Describe this medical condition:

B.

To what extent does or could this condition affect your current ability to practice

medicine in your specialty area or to perform a full range of clinical activities?

C.

What is the current status of your condition?

D.

Provide the name and address of your personal physician/health care provider who can provide information about your health condition.

Name

Telephone Number

(     )

Last

First

MI

Degree

(     )

Last

First

MI

Degree

Signature:

Date:

 




FORM F – CHEMICAL SUBSTANCES OR ALCOHOL ABUSE

 

DUPLICATE this from as necessary to complete a separate sheet for EACH chemical substance incident. Use reverse side of this form if additional space is needed.

 

Applicant Name:

Last

First

MI

Describe the substance you use:

A.

To what extent does, or could, your use of this substance affect your current ability to practice medicine in your specialty area or to perform a full range of clinical activities?

B.

Monitored by State Board Mandate (Name and Address)

C.

Monitored Voluntarily (Name and Address)

D.

Other information about the current status of your use of substances:

E.

Abstinent since (mm/yy):

F.

Provide the name and address of your personal physician/health care provider who can provide information about your treatment for alcohol or chemical substance use and can comment on what impact (if any) it has on your current/future professional practice.

Name:

Last

First

MI

Degree

Address:

Street

City

State

Zip

Telephone Number:

(     )

Signature:

Date:

 

(Source:  Amended at 26 Ill. Reg. 18416, effective December 15, 2002)

 

Section 965.APPENDIX C   Uniform UpdatingHealth Care Professional Update Data Gathering Form

 

STATE OF ILLINOIS

 

Uniform UpdatingHealth Care Professional Update Data Gathering Form

 

The Health Care Professional Credentials Data Collection Act [410 ILCS 517] requires that this form be collected from health care professionals by hospitals, health care entities, and health care plans that desire to recredential the professional.  Each hospital, health care entity, and health care plan may also require completion of supplemental forms.

 

INSTRUCTIONS

 

This form is for updating only.  Other forms are required for credentialing and for recredentialing.

 

The data marked as "Confidential Information" shall be maintained in confidence to the extent required by law.  They may be used by the health care plan, entity or hospital and by their agents for credentialing and recredentialing and internal business purposes.

 

AFFIRMATION OF INFORMATION

 

I represent and warrant that all of the information provided and the responses given are correct and complete to the best of my knowledge and belief.  I understand that falsification or omission of information will be grounds for rejection or termination, in addition to penalties provided by law.  I further agree to promptly inform all entities to which this form was sent and not rejected of any change required to be updated by the Uniform UpdatingHealth Care Professional Credentialing and Business Data Gathering Update Form.

 

I understand that this application does not entitle me to participation in any hospital, health care entity, or health plan.

 

Applicant's Signature (or electronic signature)		Type or Print Name		Date

 

**PLEASE BE ADVISED THAT EACH HOSPITAL, HEALTH CARE ENTITY, AND HEALTH CARE PLAN MAY ALSO REQUIRE COMPLETION OF AN ATTESTATION AND RELEASE OF INFORMATION.

 

NOTIFICATION OF CHANGES

 

Provider's Name:
			Last			First		MI		Degree
Date Completed:
		(mm/yy)
Date of Birth:
	(mm/yy)
Illinois Professional License Number:
Social Security Number:

 

The following sections of the Uniform Health Care and Hospital RecredentialsProfessional Recredentialing and Business Data Gathering Form contain updated information and are attached (check as appropriate).

 

		ATTACHMENTS
			Section	A.	General Information
			Section	B.	Professional Information
			Section	C.	Hospital Membership – Current & Pending
			Section	D.	Ambulatory Surgical Treatment Center Practice
			Section	E.	Work History
			Section	F.	Medical Education/Clinical Training Update
			Section	G.	Professional History:  Confidential
			Section	H.	Primary Site Information
			Section	I.	Additional Site Information

 

The updated sections are attached and the particular items updated in those sections are highlighted.

 

(Source:  Amended at 48 Ill. Reg. ______, effective ____________)